Long-Term Results and Complications Following Adjustable Gastric Banding

This study was performed to assess our long-term results with laparoscopic gastric banding in patients with an observation period of at least 9 years calculated from the date of operation. Between January 1996 and December 2000, a total of 276 patients (83% female) underwent laparoscopic gastric banding at our institution. Mean preoperative body mass index (BMI) was 44 ± 6 kg/m². BMI after 1, 5, 7, 9, and 10 years was 33 ± 6, 30 ± 6, 31 ± 6, 32 ± 7, and 31 ± 7 kg/m², respectively. Mean excess weight loss after 1 year was 57.1 ± 23.0% and after 5, 7, 9, and 10 years 73.2 ± 29.6%, 65.9 ± 29.3%, 61.8 ± 32.8%, and 64.0 ± 32.1%, respectively. Median completeness of follow-up was 80%. Of the study population, 146 (52.9%) patients had at least one complication requiring reoperation. Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. Thirty-three patients had no second bariatric operation, a Roux-en-Y gastric bypass was done in 39 patients, and six patients underwent sleeve gastrectomy. Our long-term results are good with regard to weight loss in those patients who still have their band in situ. This is accompanied by a high complication rate and a 29% band loss rate.     

Long-term results of hip arthroplasty in ambulatory patients with cerebral palsy

Osteoarthritis (OA) secondary to dislocation and dysplasia is a common problem in patients with cerebral palsy. The purpose of this study was to evaluate the results of total hip replacement (THR) in ambulatory patients with cerebral palsy. Eighteen total hip arthroplasties were performed in 16 ambulatory patients with cerebral palsy. The patient's mean age at surgery was 42 ± 8 years (range 32–58 years), and the mean follow-up was 10 ± 6 years (range 2–18 years). Data were obtained by a standardised telephone interview. There was a significant postoperative reduction in pain on the NAS (narrative analogue scale) from 8.4 preoperatively to 1.1 postoperatively (p = 0.002). At follow-up no stem had been revised. Three cups were revised for aseptic loosening at two and six years, and one cup was revised for recurrent dislocation of the hip. One hip was revised for infection 12 years after the index surgery. One hip dislocated (three months postoperatively) and was treated by closed reduction. In ambulatory patients with cerebral palsy and secondary osteoarthritis of the hip THR can provide long-term pain relief and improved function. The rate of long term complications was moderate in this series; however, the dislocation rate was higher than in standard OA cases.     

Women and men with hip fractures have a longer femoral neck moment arm and greater impact load in a sideways fall

Introduction  In a case control study, we report that women and men with hip fractures have a longer moment arm of the force applied on the proximal femur during a sideways fall, a structural feature that may contribute to fracture risk. The impact load and its direction during a sideways fall onto the greater trochanter are partly determined by the geometry of the proximal femur. We hypothesized that the hip geometry in elderly with hip fractures produces a greater impact on the hip during a sideways fall. Methods  We studied 41 female (77.2 ± 9.9 years) and 22 male (76.2 ± 12.1 years) patients with hip fractures and 40 female (85.7 ± 6.0 years) and 17 male (84.3 ± 10.1 years) controls. Hip geometry was analyzed on the nonfracture hip in patients and left hip in controls using dual-energy X-ray absorptiometry. Results  There was no difference in areal bone mineral density (aBMD), hip axis length, femoral neck axis length, or neck-shaft angle between cases and controls. However, the moment arm of the force on the hip during a sideways fall was 7.3% and 9.5% longer resulting in 5.6% and 9.1% greater moment in such a fall in female and male cases relative to their respective controls independent of height and weight (all p < 0.056). In multivariate logistic regression analysis, only the moment arm length in a sideways fall was associated with increased risk of hip fracture in females (odds ratio = 1.91, 95%CI: 1.14–3.20 for each SD increase in moment arm length of sideways fall, p = 0.02) and males (odds ratio = 2.69, 95% CI, 1.19–6.09, p = 0.01). Conclusions  A longer moment arm in the sideways fall increases the resultant force applied to the hip predisposing to hip fracture.     

Graft Survival and Complications after Laparoscopic Gastric Banding for Morbid Obesity—Lessons Learned from a 12-Year Experience

Laparoscopic adjustable gastric banding (LAGB) has been considered by many as the treatment of choice for morbid obesity because of its simplicity and encouraging early results. The aim of this prospective study was to critically assess the effects, complications, and outcome after LAGB in the long-term, based on a 12-year experience. Between June 1998 and June 2009, all patients with implantation of a LAGB have been enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications, re-operation rate, and graft survival. LAGB was performed in 167 patients (120 female, 47 male) with a mean age of 40.1 ± 5.2 years. Operative mortality was 0%, overall 1.2% (not band-related). Overall patient follow-up was 94.0%. Mean excess weight loss (EWL) after 1, 2, 5, 8, and 10 years was 31.1 ± 7.5% (p < 0.005), 44.2 ± 6.5% (p < 0.001), 50.3 ± 6.9% (p < 0.001), 51.7 ± 6.3% (p < 0.001), and 48.8 ± 6.0% (p < 0.001), respectively. The non-responder rate (EWL < 30%) after 2, 5, 8, and 10 years was 24.5%, 18.3%, 12.5%, and 16.6%, respectively. The early complication rate (<30 days) was 7.8% (13/167), with 10 minor and three major complications. Late complications (>30 days) occurred in 40.1% (67/167), of whom seven were minor and 60 were major complications (three band infections, two band migrations, 11 band leakages, two slippings/pouch dilatations, two band intolerances, and 40 esophageal dilatations). The overall re-operation rate was 20.4% (34/167). The graft survival of the implanted band after 2, 5, 8, 10, and 12 years was 98.8%, 94.0%, 86.8%, 85.0%, and 85.0%, respectively. The failure rate of the procedure after 2, 5, 8, and 10 years was 25.7%, 24.3%, 25.7%, and 31.6%, respectively. In the present long-term high-participation follow-up study, LAGB is a safe and effective surgical treatment for morbid obesity. However, the high complication, re-operation, and long-term failure rates lead to the conclusion that LAGB should be performed in selected cases only, until reliable criteria for patients at low risk for long-term complications are developed.     

Safety and Efficacy of Roux-en-Y Gastric Bypass to Treat Type 2 Diabetes Mellitus in Non-severely Obese Patients

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) < 35 kg/m² have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI < 35 kg/m². All T2DM patients with BMI < 35 kg/m² and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m², 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.     

Integrated bioabsorbable tissue reinforcement in laparoscopic sleeve gastrectomy

Division of the stomach in laparoscopic sleeve gastrectomy may be performed using bare stapler cartridges or cartridges fitted with tissue reinforcement strips, with or without oversewing. Many tissue reinforcement strips are after-market add-on products that must be fitted onto a stapler during surgery. A retrospective review was conducted of 85 consecutive patients undergoing laparoscopic sleeve gastrectomy using a novel integrated bioabsorbable polymer buttress pre-mounted on a single-use loading unit stapler. Mean preoperative body mass index (BMI) was 41.7 ± 5.2 kg/m². Morbidity and short-term outcomes were documented. Mean follow-up was 8.1 ± 3.6 months (range, 1.0–16.2 months). There were no mortalities or staple line leaks noted in this series with short-term follow up. The major complication rate (grade III and above) was 7.1% and included: reoperation for staple line bleeding (2.4%, n = 2), gastric sleeve stenosis requiring balloon dilation (2.4%, n = 2), choledocholithiasis 2 weeks after surgery (1.2%, n = 1), and reoperation without abnormality for suspected perioperative obstruction (1.2%, n = 1). Mean percent excess BMI loss at 3 (44.6 ± 11.3), 6 (57.9 ± 17.2), and 12 months (72.4 ± 27.5) was comparable to other published series. The use of an integrated absorbable synthetic polymer for stapled tissue reinforcement in laparoscopic sleeve gastrectomy appears to be feasible and safe, and yields results consistent with other published techniques.     

Age ≥50 Does Not Influence Outcome in Laparoscopic Gastric Banding

Background  Laparoscopic adjustable gastric banding is an accepted treatment for obesity. Age greater than 50 carries a theoretically increased risk from weight loss surgery and perhaps less clinical benefit in the long term. We compare results of gastric banding at age 50 and above with age below 50 in our unit. Methods  Between April 2003 and November 2007, 1,335 patients, mean weight 121.7 kg (range 73–268 kg), mean body mass index (BMI) 44.1 kg/m² (range 35–99), underwent gastric banding. Three hundred and twenty four patients had age ≥50. Band adjustments were usually carried out using fluoroscopy. Results  There was no statistically significant difference in the preoperative weights and BMIs for the two patient groups (age < 50: weight 120.7 ± 24.9, BMI 43.6 ± 7.3 kg/m²; age ≥ 50: weight 118 ± 23.7 kg, BMI 43.8 ± 7 kg/m²). Similarly, there was no statistically significant difference with regards to excess percent BMI loss in the two groups over 36 months (age < 50 = 49 ± 27.9; age ≥ 50 = 47.3 ± 35.1). There was no difference in the incidence of complications with patient age. Conclusion  These results demonstrate that, at age ≥50, this procedure is successful in producing weight loss and, at the same time, has a complication rate comparable to younger patients.     

Ten Years Experience with Laparoscopic Adjustable Gastric Banding

Background Gastric banding is a safe and efficient bariatric procedure. We report here the results of 591 consecutive gastric bandings in terms of excess weight loss with up to 10 years follow-up and the complications. Methods Between June 1996 and September 2006, 591 patients underwent laparoscopic adjustable gastric banding (LAGB) by the same surgeon (JB). Of these patients, 69.2% were women. Mean age was 33.6 years ± 10.7 and mean BMI was 41.95 kg/m² ± 8.7. Patients were reviewed monthly for the first 6 months, every 2 months for the next 6 months, and yearly thereafter. Excess weight loss was calculated at 6 months and 1, 2, 4, 6, 8, and 10 years. Results Six hundred eleven bands were implanted in 591 patients. Fifty-one patients (8.6%) had band removal due to a complication. Mean follow-up was 35 ± 2 months. Percentage of excess weight loss was 45.8% ± 27.4 at 6 months, 66.7% ± 30.3 at 1 year, 72.6% ± 28.8 at 2 years, 75.9% ± 27.4 at 4 years, 82.8% ± 32.6 at 6 years, 82.3% ± 25.1 at 8 years, and 82.7% ± 4.2 at 10 years. Complications encountered were band failure (9.3%), slippage (5.3%), erosion (4.6%), infection (2.4%), high band position (1.9%), and others (2.8%). Complication rate was 23.3% overall but dropped to 2.5% when calculated on the second half of the patients. Conclusion LAGB is a safe and efficient bariatric procedure. With experience, the complication rate drops to a very low level. Close follow-up can further increase its efficacy. Presented at 12th Annual Meeting of IFSO, Porto, Portugal, September 2, 2007.     

Laparoscopic Sleeve Gastrectomy in Ethnic Obese Chinese

Background  The aim of this study was to evaluate the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity in ethnic Chinese in Hong Kong. Methods  Seventy consecutive Chinese patients (49 females; mean age 34.7 ± 8.8 [range 18–56] years) received LSG for the treatment of obesity from May 2006 to Nov 2007 as a stand-alone procedure for weight reduction. Mean baseline body weight (BW) and body mass index (BMI) were 108.9 ± 22.1 kg (range 71.0–164.9 kg) and 40.7 ± 7.8 kg/m² (range 27.4–68.4 kg/m²), respectively. Outcome measures were collected and assessed in a prospective manner. Results  All procedures were performed laparoscopically with no conversion. There was neither mortality nor any postoperative complications that required reoperation. Major complication occurred in two patients (2.9%; esophagogastric junction [EGJ] leak and stomach tube stricture). Mean follow-up was 7.1 ± 5.0 months. Mean procedure time was 90.6 ± 39.4 min, and mean hospital stay was 3.8 ± 2.3 days. Mean BMI loss was 6.3 ± 2.5, 9.0 ± 3.4 and 12.3 ± 4.5 kg/m² at 3, 6, and 12 months. Mean percent of excess BW loss was 48.5 ± 28.4, 69.7 ± 31.7, and 63.5 ± 29.4 at 3, 6, and 12 months. Conclusion  LSG is safe and effective in achieving significant weight loss in obese ethnic Chinese patients.     

Total hip arthroplasty in patients with Down��s syndrome

Patients with Down’s syndrome (DS) have an increased incidence of coxarthrosis which may become symptomatic with prolonged life expectancy. We present seven consecutive patients (nine hips) with DS who had primary total hip arthroplasty (THA). Average clinical and radiological follow-up was 9.9 ± 6.4 years (range 2–22.25). Harris hip scores (HHS) improved significantly (p < 0.01) from 41.1 (range 18.5–65) to 80.2 (range 67.5–91) at latest follow-up. Two patients required revision arthroplasty for stem loosening at 16 (osteolysis) and six years (trauma) following THA, respectively. Six of the THAs required a constrained liner. No dislocations or deep infections were encountered. We contend that THA is a reliable surgical intervention in patients with DS and may be performed in symptomatic patients.     

Short-term efficacy of rituximab versus tacrolimus in steroid-dependent nephrotic syndrome

Although therapy with intravenous (IV) rituximab and tacrolimus reduces the relapse rate in steroid-dependent nephrotic syndrome (SDNS), studies on comparative efficacy are lacking. We retrospectively reviewed the records of patients with difficult-to-treat SDNS who had previously received levamisole, cyclophosphamide and/or mycophenolate mofetil, then treated with either rituximab or tacrolimus and followed for 12 months. Between January 2009 and April 2010, ten patients received two to three doses of IV rituximab (375 mg/m²/week) and 13 received tacrolimus (0.1–0.2 mg/kg/day) for 12 months; none had previously received either agent. Patients received tapering doses of alternate-day prednisolone; other immunosuppressive agents were discontinued. The mean age of the patients at treatment initiation with rituximab and tacrolimus was 12.2 ± 2.3 and 12.3 ± 3.0 years, respectively. The respective pre-treatment relapse rates (3.1 ± 1.1 and 3.5 ± 1.6 relapses per year) and cumulative prednisolone dose (137.2 ± 69.4 and 140.5 ± 59.0 mg/kg/year) were similar. Therapy resulted in a decline in relapse rate in both groups (P < 0.001). The number of relapses in the rituximab and tacrolimus groups was similar at 6 months (0.3 ± 0.5 vs. 0.3 ± 0.6 episodes, respectively), 12 months (0.8 ± 1.0 vs. 0.9 ± 1.1 episodes) and last follow-up (1.2 ± 1.0 vs. 1.5 ± 1.3 episodes). There were no differences in relapse-free survival at 6, 12 and 18 months. Therapy resulted in a significant decline in the cumulative prednisolone dose (67.2% in the rituximab group and 43.6% in the tacrolimus group) and a reduced body mass index. These findings suggest that in our patients with difficult-to-treat SDNS, treatment with two to three doses of rituximab was as effective as 12 months of therapy with tacrolimus in terms of steroid sparing and reduction in the relapse rate.     

Comparison of 39 post-traumatic tibia bone transports performed with and without the use of an intramedullary rod: the long-term outcomes

Bone transport can be performed with an external fixator alone or with the monorail technique which entails the combination of a fixator and an intramedullary nail. The purpose of this study was to compare the complication rates and long-term outcomes of these methods. Two groups of patients, the external fixator (n = 21) and the monorail group (n = 18), were compared. The average follow-up period was 7.9 ± 5.6 years and the mean defect length 8.3 ± 3.1 cm. Healing was achieved in 19 (90%) and 13 (72%) of the fixator and monorail patients, respectively. Six patients underwent amputations because of persistent infections (two in the fixator and four in the monorail group). The rate of deformities was significantly higher in the fixator group (p = 0.049). No statistically significant difference was found when comparing categories of the SF-36 test or the ability to work or do sports. The main advantages of the monorail method are reduction of the external fixation time and the lower rate of deformities. However, the authors recommend segmental transport with external fixator in patients with chronic infections.     

Incidence of hyponatremia in children with gastroenteritis treated with hypotonic intravenous fluids

Hypotonic saline solutions have been used for over five decades to treat children with diarrheal dehydration. However, concern has recently been raised about the potential for iatrogenic hyponatremia as a result of this therapy. We reviewed the medical records of 531 otherwise healthy children with gastroenteritis who had been admitted to the hospital for intravenous fluid therapy. We retrospectively collected data on 141 of these children who had received two serum electrolytes (one upon admission and the other 4–24 h thereafter). The remaining 390 children were excluded because their charts lacked the required data. We analyzed data in 124 of these 141 patients whose initial serum sodium (Na) level was between 130–150 mEq/l and excluded 17 patients whose admission serum sodium fell outside this range. All patients were treated with intravenous hypotonic fluids (5% dextrose in 0.2% saline, n = 4; 5% dextrose in 0.3% saline, n = 102; 5% dextrose in 0.45% saline, n = 18 patients) as maintenance fluid therapy or maintenance fluid plus deficit therapy; 100 of these children had received an initial saline bolus of 21.05 ± 8.5 ml/kg upon admission. The serum Na level decreased by 1.7 ± 4.3 mEq/l in the whole group. Of the 97 children with isonatremia (Na 139.5 ± 2.7 mEq/l) on admission, 18 (18.5%) developed mild hyponatremia (Na 133.4 ± 0.9 mEq/l, range 131–134), with a decrease in serum Na of 5.7 ± 3.1 mEq/l, and 79 remained isonatremic (Na 138.3 ± 2.7 mEq/l), with a decrease in serum Na of 1.8 ± 3.4 mEq/l (p < 0.0005). There was no significant difference in type, rate, or amount of intravenous fluid or saline bolus (26.1 ± 10.4 vs. 20.2 ± 8.6 ml/kg, respectively) administered in these two groups. Children who became hyponatremic were older (5.8 ± 2.7 years) than those who remained isonatremic (2.8 ± 3.1 years) (p < 0.0005), but there was no statistical difference in gender, degree of dehydration, and severity of metabolic acidosis between the two groups. Although serum Na increased by 3.9 ± 2.5 mEq/l in 19 patients with mild hyponatremia upon admission (Na 132.8 ± 1.3 to 136.7 ± 2.6 mEq/l) and 73% of these became isonatremic, hypotonic saline solutions have the potential to cause hyponatremia in children with gastroenteritis and isonatremic dehydration.     

The benefits of standardizing the operative procedure for the assistant in laparoscopy-assisted gastrectomy for gastric cancer

Background and aim  Laparoscopy-assisted distal gastrectomy (LADG) has not yet been widely adopted for the treatment of gastric cancers because of the perceived complexity of the procedure. In addition to the proficiency of the operator, other factors could potentially be optimized to improve postoperative outcomes. The aim of this study was to evaluate a standardized operative procedure for assistants performing LADG. Materials and methods  Of 114 patients, 64 initially underwent conventional LADG (CLDG) and then 50 underwent standardized procedure (SLDG) in which the role of assistant in LADG was completely established. Parameters compared for the SLDG and CLDG groups were operation time, estimated blood loss, intra- or postoperative complications, preservation of the vagus nerve, and the number of pathologically examined lymph nodes. Results  The operation time for the SLDG procedure (mean ± SE, 229 ± 6 min) was shorter than for the CLDG procedure (261 ± 8 min; P < 0.002), and the estimated blood loss for SLDG (57 ± 7 ml) was less than for CLDG (108 ± 17 ml, P < 0.004). The celiac branch of the vagus nerve was preserved in 73% of SLDG patients compared with 52% of CLDG patients (P < 0.03). More lymph nodes were pathologically examined in SLDG patients (38.3 ± 1.5) than in CLDG patients (32.5 ± 1.8, P = 0.02). Conclusions  Standardization of the LADG procedure for assistants enabled a shorter operation time, reduced blood loss, a higher rate of vagus nerve preservation, and more accurate lymph node dissection.     

Rhabdomyolysis After Bariatric Surgery by Roux-en-Y Gastric Bypass: A Prospective Study

Background  Obesity is a worldwide epidemic associated to comorbidities and increased mortality. Because it is chronic and recurrent and has little response to clinical measures, surgical treatment (bariatric surgery) is a therapeutic option frequently used. Different surgical complications have been associated with this type of procedure, but there is little knowledge about neuromuscular complications. Among the latter, rhabdomyolysis (RML), described a few years ago, has not been well characterized to date. Methods  We have studied 22 consecutive patients who underwent surgical treatment with open Roux-en-Y gastric bypass (RYGBP) for morbid obesity in a university hospital. A database was created including the following information of each patient: gender, age, body mass index (BMI), comorbidities, surgical time, pre- and postoperative creatine phosphokinase (CPK) dosages, and neuromuscular symptoms after surgery. The main outcome measure was the frequency of RML using CPK dosage after 24 h of surgery. RML was diagnosed as an increase of more than five times the superior limit of normal range of CPK. Results  Fourteen women and eight men were evaluated, with median age of 39.9 ± 11.2 years, median BMI of 52.4 ± 8.0 kg/m² and mean surgical time of 253.2 ± 51.9 min. The mean value of postoperative CPK was 7,467.7 ± 12,177.1 IU/L, being greater than 5,000 IU/L in 40.9% of the patients. RML was diagnosed in 17 (77.3%) patients. No patient had renal failure caused by RML, but there was one death (4.5%) related to abdominal infectious complications. Clinical neuromuscular symptoms occurred in 45% of patients, and muscular pain was the most common one, especially in gluteus region. Comparative analyzes between patients without and with RML diagnosis showed that longer surgical time (p = 0.005), and occurrence of neuromuscular symptoms (p = 0.04) were more common in the latter. Conclusion  The results of this study are similar to few other investigations and confirm that RML in open bariatric surgery with RYGBP (Capella) is a common complication. A longer surgical time can be involved in RML pathogenesis, and muscular pain is suggestive of RML occurrence.     

Inadequate Weight Loss vs Secondary Weight Regain: Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass

Background  Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. Methods  A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. Results  All procedures were completed laparoscopically within a mean duration of 219 ± 52 (135–375) min. Mean body weight was reduced from 131 ± 22 kg (range 95–194) at time of the RYGBP to 113 ± 25, 107 ± 22, and 100 ± 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 ± 9.9%, 40.5 ± 12.3%, and 50.8 ± 15.2%. No statistically significant differences were found comparing weight loss within these two groups. Conclusion  RYGBP was able to achieve EWLs of 37.6 ± 16.1%, 48.5 ± 15.1%, and 56.9 ± 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.     

Total laparoscopic gastric mobilization for esophagectomy

Background and aims  The operative mortality and morbidity associated with esophageal surgery has been decreasing with advances in surgical techniques and equipment, however, postoperative complication remains a major cause of a potentially fatal outcome. We herein describe a new technique for esophagectomy by total laparoscopic gastric mobilization technique as a minimally invasive surgery. Patients and methods  Between April 2003 and August 2007, 36 patients who were suffering from esophageal cancer were surgically resected at Kochi Medical School. Operation-related parameters, mortality, postoperative complication, intubation time, and length of surgical intensive care unit in patients with total laparoscopic gastric mobilization for esophagectomy (the TLGM group, n = 16) were evaluated, compared to patients with ordinary thoraco-abdominal esophagectomy (the OPEN group, n = 20). Results  There was no mortality in the TLGM group and one hospital death in the OPEN group. Operation time of the OPEN group (506 ± 64 min) was significant shorter than that of the TLGM group (558 ± 67 min). The estimated intraoperative blood loss volume in patients of the TLGM group (496 ± 259 mL) was much smaller than those of the OPEN group (1,067 ± 566 mL). The intubation time and the intensive care unit stay in the TLGM group were much shorter than that in the OPEN group. Conclusions  Esophagectomy with regional lymphadenectomy combined with total laparoscopic gastric mobilization is a safe and beneficial opportunity for patients who underwent surgical procedure for esophageal cancer.     

Establishing Laparoscopic Roux-en-Y Gastric Bypass: Perioperative Outcome and Characteristics of the Learning Curve

Background  Bariatric surgery was established at several Norwegian hospitals in 2004. This study evaluates the perioperative outcome and the learning curves for two surgeons while introducing laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods  Morbidly obese patients undergoing primary LRYGB were included. Lengths of surgery and postoperative hospital stay, and 30-day rates of morbidity, reoperations, and readmissions were set as indicators of the learning curve. Learning effects were evaluated by graphical analyses and comparing the first and last 40 procedures for both surgeons. Results  The 292 included patients had a mean age of 40.0 ± 9.5 years and a mean body mass index (BMI) of 46.7 ± 5.3 kg/m². The mean length of surgery was 101 ± 55 min. Complications occurred in 43 patients (14.7%), with no conversions to open surgery in the primary procedure and no mortality. Reoperations were performed in 14 patients (4.8%), of which five patients required open surgery. The median length of stay was 3 days (range 1–77), and 19 patients (6.5%) were readmitted. High patient age, but not high BMI, was associated with an increased risk of complication. For both surgeons, lengths of surgery and hospital stay were significantly reduced (p < 0.001), leveling out after 100 procedures. Reductions in the rates of morbidity, reoperations and readmissions were not found. Conclusion  LRYGB was introduced with an acceptable morbidity rate and no mortality. Only the length of surgery and postoperative hospital stay were suitable indicators of a learning curve, which comprised about 100 cases.     

Chiari pelvic osteotomy in the treatment of adolescent hip disorders: possibilities, limitations and complications

Ninety-nine hips treated by the Chiari pelvic osteotomy were included in this study designed as a retrospective review. The group consisted of 36 male and 50 female patients, with mean age of 15.6 years. Each was diagnosed with developmental dysplasia of the hip (DDH) or avascular necrosis of the femoral head—Legg-Calve-Perthes disease (LCP)—and postreduction avascular necrosis (PAN). Five hip parameters (the acetabular angle of Sharp, the center-edge (CE) angle of Wiberg, the percentage of femoral head uncoverage, the acetabular depth ratio, and the Shenton-Menard arch continuity) were evaluated. Functional outcome was assessed according to Harris hip score (HHS) and McKay criteria for clinical evaluation. The postoperative results showed improvement in all the radiographic parameters. The angle of Sharp showed a decrease of 8.62o (p < 0.01). The CE angle of Wiberg showed an increase of 28.76o (p < 0.01), and the uncoverage of the femoral head showed a decrease of 51.51% (p < 0.01). The improvement of HHS was 11.93 (p < 0.05). The patients’ satisfaction was indicated by grade 4.1 ± 0.94 and the doctor’s satisfaction by grade 3.7 ± 1.16. The Chiari pelvic osteotomy, in spite of the development of biologically better procedures, has retained its position in the treatment of adolescent hip disorders.