Inflammatory response after laparoscopic and conventional colorectal resections – results of a prospective randomized trial

Background: Short-term benefits of laparoscopic relative to conventional colorectal resections have been demonstrated in randomized controlled trials. It has been suggested that a diminished cytokine and acute-phase response may be responsible for these advantages. Methods: In a randomized controlled trial, patients underwent laparoscopic (n=30) or conventional (n=30) resection of colorectal tumors. Plasma levels of interleukin-1 receptor antagonist (IL-1RA), interleukin-6 (IL-6), interleukin-10 (IL-10), and C-reactive protein (CRP) were analyzed repeatedly. Postoperative peak levels and area under the curve values were calculated and compared between groups using the Mann-Whitney U-test. Results: Patient characteristics, preoperative cytokine, and CRP plasma levels were not different between each group. Postoperative peak concentrations of IL-6 (P=0.05) and CRP (P<0.001) and the overall postoperative plasma concentrations of IL-6 (P=0.03) and CRP (P=0.002) were lower in the laparoscopic than in the conventional group. Peak and overall IL-1RA (P=0.2; P=0.2) and IL-10 (P=0.4; P=0.6) plasma concentrations, respectively, were not different between groups. Conclusions: IL-6 and CRP plasma levels were lower after laparoscopic than conventional colorectal resections. The less intense inflammatory response may be an indicator of the milder surgical trauma inflicted by laparoscopic than conventional colorectal resection. Received: 31 March 1999; in revised form: 15 July 1999 Accepted: 20 August 1999     

Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients – analysis of the MBSAQIP

Background

An increase in the prevalence of obesity and longer life expectancy has resulted in an increased number of candidates over the age of 60 who are pursuing a bariatric procedure.

Influence of post–Roux-en-Y gastric bypass weight recidivism on insulin resistance: a 3-year follow-up

BackgroundAlthough some early metabolic benefits provided by bariatric surgery are known to occur regardless of weight loss, the impact of mid- to long-term weight recidivism after Roux-en-Y gastric bypass (RYGB) on metabolic outcomes is not profoundly understood.ObjectiveTo investigate the effect of weight recidivism on insulin resistance among nondiabetic individuals with morbid obesity after RYGB during a 3-year follow-up.SettingPublic tertiary university hospital.MethodsThis is a cohort study based on a prospectively collected database of a public tertiary university hospital, which enrolled individuals with morbid obesity who underwent RYGB and were followed-up for 3 years. Weight loss was classified into the following 3 categories: (1) no weight regain; (2) expected regain (regain ≤20% of the maximum weight loss); and (3) obesity recidivism (regain >20% of the maximum weight loss). Homeostasis model assessment (HOMA) values were compared over time.ResultsOf 100 patients, 20% presented obesity recidivism and 52% an expected regain after 3 years of surgery; 28% showed no regain. The recidivism group presented a significant increase in HOMA 3 years after surgery (P = .02). The recidivism group presented a significantly higher HOMA 3 years after surgery than the observed in the other groups (P < .001), as well as a significantly higher percentage of HOMA variation throughout the follow-up (P = .02).ConclusionWeight recidivism after RYGB was significantly associated with a worsening of insulin resistance among nondiabetic individuals with morbid obesity. Thus, weight loss seems to play a significant role in the maintenance of the early metabolic improvement achieved after RYGB.     

Bowel obstruction after laparoscopic and open colon resection for cancer: Results of 5?years of follow-up in a randomized trial

Background

Postoperative bowel obstruction caused by intra-abdominal adhesions occurs after all types of abdominal surgery. It has been suggested that the laparoscopic technique should reduce the risk for adhesion formation and thus for postoperative bowel obstruction. This study was designed to compare the incidence of bowel obstruction in a randomized trial where laparoscopic and open resection for colon cancer was compared.

Methods

A retrospective analysis was performed, collecting data of episodes of bowel obstruction with or without surgery. Only episodes treated in the hospital where the index surgery took place were included. Data for 786 patients were collected for the 5-year period after cancer surgery.

Results

Baseline characteristics for the evaluated laparoscopic (n?=?383) and open (n?=?403) groups were comparable. The cumulative obstruction percentages at 5?years for the open and laparoscopic groups were 6.5 and 5.1% respectively and did not significantly differ from each other. Tumor stage seemed to influence the risk for bowel obstruction: 2.8% in stage I, 6.6% in stage II, and 7% in stage III, but the differences were not significant.

Conclusions

This analysis does not support the hypothesis that laparoscopy leads to fewer episodes of bowel obstruction compared with open surgery.     

Evaluation of the effectiveness of a semi-finished occlusal appliance – a randomized, controlled clinical trial

Introduction

Painful temporomandibular disorders (TMDs) are usually treated with physiotherapy, self-exercises, medication-based therapy and splint therapy. For splint therapy different types of splints are available. Therefore this randomized controlled study compared the effectiveness of a semi-finished occlusal appliance (SB) with a laboratory-made occlusal appliance (SS) in myofascial pain patients.

Method

The trial subjects allocated to the experimental groups with the (SB) occlusal appliance and those provided with a laboratory-made occlusal appliance (SS) did, in addition, receive conservative treatment (self-exercises, drug-based and manual therapy). The control group was given conservative therapy (CO) only. Overall, a total of 63 patients participated in the study with each group consisting of 21 subjects.

Results

When the first follow-up examination took place (14 days after splint insertion) mouth opening within the SB group was significantly enlarged. When the second examination was conducted (2.5 months after splint insertion) mouth opening was significantly enlarged in both splint groups when compared with the initial value. In the control group, no significant enlargement of mouth opening was detected. At no point there was a significant reduction in the number of pressure-sensitive areas of the TMJ. On palpation of the masticatory muscles however, a significant reduction in the number of pressure-sensitive areas could be observed within the CO group and the SS group after 2.5 months. When comparing pain reduction (muscle/joint pain) and mouth opening, no significant differences could be detected between the treatments.

Conclusion

The results suggest that TMD should be treated conservatively. In cases of restricted mouth opening, the additional use of occlusal appliances can eliminate the patient’s discomfort more quickly. In this context, the tested, semi-finished occlusal appliance appears to offer an immediately available, temporary alternative to laboratory-made splints.     

Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial

BackgroundRoux-en-Y gastric bypass surgery is the leading surgical treatment of morbid obesity in the United States. The role of preoperative weight loss in gastric bypass surgery remains controversial. We performed a prospective randomized trial to determine whether preoperative weight loss results in better outcomes after laparoscopic gastric bypass.MethodsA total of 100 patients undergoing laparoscopic gastric bypass surgery from May 2004 to October 2005 were randomized preoperatively to either a weight loss group with a 10% weight loss requirement or a group that had no weight loss requirements. The patients were followed prospectively. The variables analyzed included perioperative complications, operative time, postoperative weight loss, and resolution of co-morbidities.ResultsData were available for 26 patients in the weight loss group and 35 in the nonweight loss group. The 2 groups had similar preoperative characteristics, conversion and complication rates, and resolution of co-morbidities. The initial body mass index was 48.7 kg/m² and 49.3 kg/m² for the weight loss group and nonweight loss group, respectively (P = NS). The preoperative body mass index was 44.5 kg/m² and 50.7 kg/m² for the weight loss group and nonweight loss group, respectively (P = 0.0027). The operative time was 220.2 and 257.6 minutes for the 2 groups (P = 0.0084). The percentage of excess weight loss at 3 and 6 months for the weight loss group and nonweight loss group was 44.1% and 33.1% (P = 0.0267) and 53.9% and 50.9% (P = NS), respectively. The interval to surgery from the initial consultation was 5.4 months and 5.2 months for the 2 groups (P = NS).ConclusionsPreoperative weight loss before laparoscopic Roux-en-Y gastric bypass was associated with a decrease in the operating room time and an improved percentage of excess weight loss in the short term. Preoperative weight loss, however, did not affect the major complication or conversion rates, and its long-term effects were not apparent through this study. Also, preoperative weight loss did not have any bearing on the resolution of co-morbidities.     

Warm-up on a simulator improves residents’ performance in laparoscopic surgery: a randomized trial

Introduction and hypothesis

Our aim was to assess the impact of immediate preoperative laparoscopic warm-up using a simulator on intraoperative laparoscopic performance by gynecologic residents.

Methods

Eligible laparoscopic cases performed for benign, gynecologic indications were randomized to be performed with or without immediate preoperative warm-up. Residents randomized to warm-up performed a brief set of standardized exercises on a laparoscopic trainer immediately before surgery. Intraoperative performance was scored using previously validated global rating scales. Assessment was made immediately after surgery by attending faculty who were blinded to the warm-up randomization.

Results

We randomized 237 residents to 47 minor laparoscopic cases (adnexal/ tubal surgery) and 44 to major laparoscopic cases (hysterectomy). Overall, attendings rated upper-level resident performances (postgraduate year [PGY-3, 4]) significantly higher on global rating scales than lower-level resident performances (PGY-1, 2). Residents who performed warm-up exercises prior to surgery were rated significantly higher on all subscales within each global rating scale, irrespective of the difficulty of the surgery. Most residents felt that performing warm-up exercises helped their intraoperative performances.

Conclusion

Performing a brief warm-up exercise before a major or minor laparoscopic procedure significantly improved the intraoperative performance of residents irrespective of the difficulty of the case.     

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

Background

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.

Methods

This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).

Results

Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and “atypical” extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.

Conclusions

Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.     

Transvaginal hybrid NOTES cholecystectomy—results of a randomized clinical trial after 6 months

Introduction

For cholecystectomy (CHE), both the needlescopic three-trocar technique with 2–3-mm instruments (needlescopic cholecystectomy (NC)) and the umbilically assisted transvaginal technique with rigid instruments (transvaginal cholecystectomy (TVC)) have been established for further reduction of the trauma remaining from laparoscopy.

Methods

To compare the further outcome of both techniques for elective CHE in female patients, we analyzed the secondary end points of a prospective randomized single-center trial (needlescopic versus transvaginal cholecystectomy (NATCH) trial; ClinicalTrials.gov Identifier: NCT0168577), in particular, satisfaction with aesthetics, overall satisfaction, abdominal pain, and incidence of trocar hernias postoperatively at both 3 and 6 months. After 3 months, the domains “satisfaction” and “pain” of the German version of the Female Sexual Function Index (FSFI-d) were additionally evaluated to detect respective complications. A gynecological control examination was conducted in all TVC patients after 6 months.

Results

Forty patients were equally randomized into the therapy and the control groups between February 2010 and June 2012. No significant differences were found for overall satisfaction with the surgical result, abdominal pain, sexual function, and the rate of trocar hernias. However, aesthetics were rated significantly better by TVC patients both after 3 and after 6 months (P?=?0.004 and P?<?0.001). There were no postoperative pathological gynecological findings.

Conclusions

Following TVC, there is a significantly better aesthetic result as compared to NC, even at 3 and 6 months after the procedure. No difference was found for sexual function.     

No influence of ibuprofen on bone healing after Colles’ fracture – A randomized controlled clinical trial

IntroductionNonsteroidal anti-inflammatory drugs (NSAIDs) may delay bone healing. This knowledge is mainly derived from retrospective uncontrolled clinical studies and from animal experiments. The purpose of this prospective controlled study was to investigate whether ibuprofen influences pain, function, and bone healing after a Colles’ fracture.Patients and methodsA single center, triple-blind, randomized clinical trial. 95 patients, 80 females and 15 males, with displaced Colles’ fracture aged median 65 (range 40–85) years old were included and operated by external fixation from June 2012 through June 2015. 89 participants received interventional medicine and 83 completed the one-year follow-up. The 7-day ibuprofen group received 600 mg of ibuprofen three times a day, the 3-day ibuprofen group received ibuprofen for three days and a placebo for the following four days, and finally, the placebo group received a placebo for seven days. All patients received paracetamol 1000 mg four times a day and 50 mg tramadol if needed. The primary outcome were radiological changes in radius tilt, length, and inclination observed during and 6 weeks after the surgery. The analgesic outcome were 14 days experience of pain, and registered use of tramadol. The functional outcomes were the percentage differences in the motion between the injured and non-injured wrist, and the DASH score at 3 and 12 months. All analyses were performed according to the intention to treat.ResultsNo clinically relevant difference was observed in the radiological migration between the treatment groups, 0.064≤P ≤ 0.81. There was no difference in the pain score between the treatment groups, P = 0.13. The use of tramadol was lower in the ibuprofen groups than in the placebo group, P = 0.035. Ibuprofen treatment did not affect the range of motion, 0.148 ≤P ≤ 0.963. Patients in all groups demonstrated DASH score, and wrist motion improvement, close to 90% of normal amplitude. The complication rate was higher in the 7-day ibuprofen group compared to the placebo group, P = 0.043.ConclusionsIbuprofen treatment demonstrated a tramadol-sparing effect during the postoperative period. Neither wrist function nor radiological migration were influenced. The complication rate was higher in the ibuprofen-treated group compared the placebo-treated group.     

Complications after laparoscopic Roux-en-Y gastric bypass: a diagnostic challenge. Report of three cases and review of the literature

The number of Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) procedures for morbid obesity and type 2 diabetes mellitus will increase worldwide, and therefore, an increase in perioperative morbidity can be anticipated. The authors present three cases based on different complications after LRYGB to demonstrate the diagnostic challenge that clinicians face in this particular group of patients. Also, a review of the literature covering the value of different imaging in these particular cases is provided by the authors. The role of imaging in the diagnostic process is discussed.     

Retained gastric band port and tube 5 years after gastric band removal and laparoscopic Roux-en-Y gastric bypass: a case report

Background

While LAGB has become uncommon in the bariatric surgery practice, band removal with or without revision surgery is still common. Retained postoperative foreign body, of which surgical sponges are the most common, is a rare condition. We report a rare case of retained gastric band port and the attached tube.

Case presentation

A 31-year-old Caucasian female presented to the outpatient clinic, 5?years after her last surgery, complaining of a left upper quadrant abdominal mass over the last 2?years. She had a history of 2 weight loss operations. She had no significant family history nor smoking. CT of the abdomen and pelvis revealed a retained foreign body. On exploration, the port with 10?cm of the connected tube was found and removed through a small incision without laparotomy. The patient made an uneventful recovery.

Conclusion

A bariatric surgeon should be involved in the evaluation of any patient who complains of abdominal pain and/or palpable mass if she/he has a previous weight loss procedure because the bariatric surgeon is fully aware of the possible complications of the bariatric surgeries.

     

Band erosion after laparoscopic gastric banding: a retrospective analysis of 865 patients over 5 years

Background  

Gastric band erosion is a well-reported complication after laparoscopic adjustable gastric banding (LAGB). The published literature is limited and inconclusive with regard to its management. The authors therefore reviewed all band erosions detected during a 5-year period in a high-volume bariatric practice. Because a significant proportion of the band insertions (65%) were undertaken by an operator beyond his learning curve, the authors hoped to gain a mature, comprehensive understanding of this significant complication.     

Chronic abdominal pain and quality of life after Roux-en-Y gastric bypass and sleeve gastrectomy – a cross-cohort analysis of two prospective longitudinal observational studies

BackgroundChronic abdominal pain (CAP) after bariatric surgery is not extensively explored and may impact the postoperative outcomes.ObjectiveTo compare the prevalence of patient-reported chronic abdominal pain (CAP) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Secondarily, we compared other abdominal and psychological symptoms and quality of life (QoL). Preoperative predictors of postoperative CAP were also explored.SettingTertiary referral centers for bariatric surgery in Norway.MethodsAnalyses of 2 separate prospective longitudinal cohort studies evaluating CAP, abdominal and psychological symptoms and QoL before and 2 years after RYGB and SG.ResultsFollow-ups were attended by 416 patients (85.8%), 300/416 (72.1%) were females and 209/416 (50.2%) were RYGB procedures. At follow-up, the mean age was 44.9 (10.0) years, BMI 29.5 (5.4) kg/m², and total weight loss 31.6 (10.3) %. The prevalence of CAP was 28/236 (11.9%) before and 60/209 (28.7%) after RYGB (P < .001) and 32/223 (14.3%) before and 50/186 (26.9%) after SG (P < .001). Gastrointestinal symptom rating scale scores showed greater deterioration of diarrhea and indigestion after RYGB and reflux after SG. The improvement in depression symptoms was greater after SG, as well as several QoL scores improved more after SG. Patients with CAP after RYGB experienced deterioration in several QoL scores, while these scores improved in patients with CAP after SG. Preoperative hypertension, bothersome reflux symptoms, and CAP predicted postoperative CAP.ConclusionsThe prevalence of CAP increased comparably after RYGB and SG, with worsening of gastroesophageal reflux after SG and greater deterioration of diarrhea and indigestion after RYGB. In patients with CAP at follow-up, several QoL scores improved more after SG than RYGB.     

TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial

Background

Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain.

Methods

Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)].

Results

A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13–0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09–0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups.

Conclusions

Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients’ ability to perform strenuous activities such as sports more than TEP patients.