Gastric Banding: Advantages and Complications. A 5- and 10-Year Follow-up

Background: Gastric banding is one of the simplest surgical procedures for the treatment of morbid obesity. We performed more than 150 ‘laparotomy’ (open) gastric bandings and more than 50 ‘laparoscopic’ bandings in the last 10 years. Methods: In most procedures we used non-adjustable bands, but since the beginning of 1995 we have used adjustable silicone banding. Results: The 5- and 10-year follow-up weight loss results are encouraging. The average long-term weight loss was 35.5 kg. Since 1993, we performed all the procedures laparoscopically, and the postoperative complications decreased from 18.5% in the ‘laparotomy’ group to 9.5% in the ‘laparoscopic’ group, with the majority being esophagitis and outlet area irritation. Conclusion: Gastric banding itself and especially the minimally invasive laparoscopic approach is an easy technical procedure. The long-term weight loss results and the reoperation rate are acceptable for bariatric surgery criteria.     

Biomechanical considerations in ‘biological’ femoral osteosynthesis: an experimental study of the ‘bridging’ and ‘wave’ plating techniques

Although traditional compression plate fixation aims to abolish interfragmentary movement and achieve primary bone healing, the more recent ‘biological’ plate fixation methods such as the ‘bridging’ and ‘wave’ plate techniques aim to maintain fracture alignment without absolute stability and promote union by callus formation. Furthermore, some mechanical advantages have been attributed to the ‘wave’ plate fixation. Since no data have been published on the mechanical characteristics of the ‘bridging’ and ‘wave’ plate fixation methods, the aim of this biomechanical comparative study was to investigate the rigidity of those fixation methods in various types of femoral diaphyseal fractures. Using a composite femoral model, the rigidity characteristics of three fixation methods (short DCP, ‘bridging’ and ‘wave’ plates) were investigated. The results showed that when cortical contact between the main fragments is present, a ‘bridging’ plate can be equally rigid to the ‘wave’ plate in mediolateral bending by displaying a similar tension-band effect. Furthermore, in the absence of cortical contact, the axial fixation rigidity of the long ‘bridging’ plate is superior to that of the ‘wave’ plate. Both methods showed a significant ‘stress-shielding’ effect on the intact femur. In conclusion, this in vitro study failed to show any significant mechanical advantages of the ‘wave’ plate technique over the ‘bridging’ plating method. It appears that the ‘bridging’ plate fixation may be the mechanically optimal ‘biological’ plating method for the femoral diaphysis. Received: 26 May 1999     

Laparoscopic Adjustable Esophagogastric Banding: a Preliminary Experience

Background: Laparoscopic adjustable gastric banding is an efficient surgical method in the treatment of morbid obesity. In order to reduce the number of complications, we have modified the technique to what we term ‘laparoscopic adjustable esophagogastric banding’. Methods: Between December 1994 and July 1997, 126 laparoscopic adjustable banding procedures were carried out. Of these, 40 underwent a gastric banding operation (group 1), and 86 underwent an esophagogastric banding procedure (group 2). Results: The percentage loss of excess body weight curve was less rapid in group 2 compared to group 1 due to a different strategy in band filling. Follow-up to date shows that no problems with the pouch or the stoma have arisen in the esophagogastric banding group. Conclusions: Laparoscopic adjustable esophagogastric banding is a simpler and safer procedure than laparoscopic adjustable gastric banding. It also works as a very efficient anti-reflux procedure, at least in the short term. It appears to be equally efficient as a weight-reducing operation as gastric banding. Further follow-up of the patients involved is necessary in order to evaluate the results in the longer term.     

Time to differentiate ‘decreased kidney function’ from ‘kidney disease’: towards improving the definition of chronic kidney disease

Chronic kidney disease (CKD) has become an ‘epidemic’ worldwide, since the publication of K/DOQI guidelines in 2002. This classification indeed has raised the profile of CKD worldwide. However, despite limitations of the glomerular filtration rate (GFR) estimating equations, the majority of this epidemic is caused by the large number of persons with stage 3 CKD, with many elderly individuals with ‘low-normal GFR’ being diagnosed with CKD, when, in fact, the majority of those may not have the disease, and a handful of resources being utilized in investigating these relatively ‘low-risk patients’ with ‘decreased eGFR’ without CKD. Recently, concerns have been raised by nephrologists about this classification system, and I strongly feel that it is important to differentiate ‘decreased kidney function’ from ‘kidney disease’, as the GFR estimating equations predict renal function only and nothing else; therefore, I propose some modifications to improve the current classification, so that limited resources and efforts are effectively focused on managing high-risk patients.     

Laparoscopic incisional hernia repair: a review of the literature

Incisional hernia is a common long-term complication of abdominal surgery. Historically the open repair with or without mesh was the mainstay of treatment. However, many recently published laparoscopic repair studies have challenged surgeons to re-evaluate which technique provides the best short and long-term outcomes. A Medline search of all English-language literature was performed using the keywords ‘incisional’, ‘ventral’, ‘hernia’, ‘laparoscopic’, and ‘open’. Further references were obtained by cross-referencing the bibliography in each paper. Current evidence suggests that the laparoscopic incisional hernia repair is the optimal surgical treatment. A laparoscopic repair appears to shorten hospital stay, decrease perioperative complication rates, and decrease recurrence rates. However, there is no randomized trial utilizing a standardized complication grading system making it difficult to draw a definitive conclusion as to which repair is best.     

Proximal Tibial Sleeve Fracture: Case Report of a Rare Injury and Review of the Literature

A sleeve fracture occurs when a ‘‘sleeve’’ of cartilage or periosteum is avulsed with or without an osseous fragment, an injury most commonly reported in the patella. Proximal tibial sleeve fractures are extremely rare and we present a case in an adolescent male who had concomitant osteochondral as well as chondral fractures of his patella. Sleeve fractures present in the skeletally immature, and may look relatively benign on radiographs, but misdiagnosis may lead to adverse consequences. Clinicians should have a high index of suspicion if a child or adolescent presents with a knee injury with clinical concerns regarding the extensor mechanism. Given that the ‘‘sleeve’’ of the injury contains tissue with osteogenic potential, we recommend that displaced proximal tibial sleeve fractures should be managed operatively to avoid dysfunction of the extensor mechanism. These patients should also have perioperative assessment for occult osteochondral and chondral injuries that are potentially repairable and thus may have implications for prognosis.     

Two-level contiguous cervical disc disease treated with peek cages packed with demineralized bone matrix: results of 3-year follow-up

Interbody cages are widely used instruments for cervical fusion operations. Long-term follow-up studies are needed to clarify if these devices are dependable. In this prospective study, 79 patients (42 women and 37 men) with a mean age of 51 years operated between January 2000 and December 2005 for treatment of degenerative cervical disc disease and spondylosis associated with radiculopathy or myelopathy were evaluated. Patients underwent two-level contiguous anterior cervical discectomy and fusion operations with standard anterior Smith–Robinson approach. To achieve fusion PEEK cages packed with demineralized bone matrix mixed with autologous blood were used. Clinical outcome was evaluated with Odom’s criteria and results were evaluated as ‘excellent’, ‘good’, ‘fair’ and ‘poor’. Spinal curves, mobility and fusion status were assessed with anterior–posterior and lateral (neutral, flexion and extension) radiographs obtained before surgery and at 3, 12, 24 and 36 months postoperatively. The Ishihara curvature index (ICI) was used for spinal curve evaluation. Lateral dynamic (flexion and extension) radiographs at postoperative 12th month revealed the fusion status classified as 1A, 1B, 2A and 2B. The radiological outcomes were classified as ‘non-fusion’ when 2B healing was observed, and as ‘fusion’ when 1A, 1B or 2A healing was observed at the levels subjected to surgery. According to Odom’s criteria, clinical outcomes were classified as ‘excellent’ or ‘good’ in 69 patients (success rate: 87.3%). Eight patients were graded as ‘fair’ and two as ‘poor’. Preoperative mean ICI was 10.4 ± 3.72 and postoperative mean ICI was 10.1 ± 3.14. The difference was statistically insignificant (P > 0.05); therefore, preoperative lordosis was said to be preserved at final follow-up. Final fusion rate (Types 1A, 1B, and 2A) was 91.7% (145/158 levels). Radiological imaging showed no cage failure or dislodgement and reoperation due to non-fusion was not needed.     

‘Slowing Down When You Should’: Initiators and Influences of the Transition from the Routine to the Effortful

Background  

‘Slowing down when you should’ has been described as marking the transition from ‘automatic’ to ‘effortful’ functioning in professional practice. The ability to ‘slow down’ is hypothesized as an important factor in expert judgment. This study explored the nature of the ‘slowing down’ phenomenon intraoperatively and its link to surgical judgment.     

What Do Patients, Families and Society Expect From The Bariatric Surgeon?

The expectations of patients, their families and society of the bariatric surgeon are often unrealistic, but for different reasons. The morbidly obese patient often expects ‘everything’ from bariatric surgery. The patient's family is frequently ambivalent. Society, on the other hand, tends to unrealistically regard the morbidly obese as billboards advertising them as willful deviants whose problems can all be resolved by ‘just pushing away from the table’. This invalid stereotype has prompted some to incorrectly regard bariatric surgery as an undeserved reward for individuals who will not control their own behavior. The undeserved intentional deviant status of the morbidly obese causes members of society to harass, mock or otherwise mistreat this subpopulation. Society's harmful, destructive and unjust weight harassment ‘fat-ism’ has made the morbidly obese modern day moral equivalents of lepers. We conclude that society must be persuaded to accept weight harassment as ‘politically incorrect’, subject to the same consequences as any other form of bigotry. Once society regards the morbidly obese as victims, not perpetrators, of their nonsurgically curable disease, bariatric surgery results should become held to similar standards as surgery for carcinoma, cardiovascular and other diseases. Until then, the morbidly obese remain the last true bastion of prejudice.     

A modified Delphi approach to standardize low back pain recurrence terminology

Lack of standardization of terminology in low back pain (LBP) research has significantly impeded progress in this area. The diversity in existing definitions for a ‘recurrence of an episode of LBP’ and ‘recurrent LBP’ is an important example. The variety of definitions used by researchers working in this area has prevented comparison of results between trials and made meta-analyses of this data unfeasible. The aim of this study was to use a modified Delphi approach to gain consensus on definitions for a ‘recurrence of an episode of LBP’ (e.g. outcome event) and for ‘recurrent LBP’ (e.g. patient population). Existing definitions for both constructs were classified into the main features comprising the definition (e.g. ‘duration of pain’) and the items that defined each feature (e.g. ‘pain lasting at least 24 h’). In each round, participants were asked to rate the importance of each feature to a definition of a ‘recurrence of an episode of LBP’, and a definition of ‘recurrent LBP’ and rank the items (defining each feature) in order of decreasing importance. Forty-six experts in LBP research, from nine different countries, participated in this study. Four rounds were completed with responses rates of 94, 91, 83, and 97% in rounds 1, 2, 3, and 4, respectively. Consensus definitions were reached in both areas with 95% of panel members supporting the definition of a ‘recurrence of an episode of LBP’ and 92% of panel members supporting the definition of ‘recurrent LBP’. Future research is necessary to evaluate these definitions.     

Kyphotic deformity in spinal tuberculosis and its management

Spinal tuberculosis is the most common cause of severe kyphosis in many parts of the world. Three percent of patients treated conservatively end up with a deformity greater than 60 degrees which can cause serious cosmetic, psychological, cardio-respiratory and neurological problems. Severe kyphotic deformities are usually the result of childhood spinal deformities and ‘Spine at risk’ radiological signs are helpful to identify children at risk of deformity. In children, a severe type of collapse, termed as ‘Buckling Collapse’ is also noted where the kyphosis is more than 120 degrees. Risk factors for buckling collapse include an age of less than seven years at the time of infection, thoracolumbar involvement, loss of more than two vertebral bodies and the presence of radiographic ‘Spine-at-risk’ signs. In correction of established deformity, posterior only surgery with a variety of osteotomies is now preferred. In patients with deformity of more than 90 degrees, an opening-closing wedge osteotomy must be done to prevent neurological deficit.     

Transvaginal-hybrid vs. single-port-access vs. ‘conventional’ laparoscopic cholecystectomy: a prospective observational study

Purpose  

In the recent past, access to the peritoneal cavity has involved primarily ‘natural orifice transluminal’ and ‘single-port access’ techniques, which are based on laparoscopy. The most frequently performed procedure using these new developments is cholecystectomy. Few studies compare more than one ‘new’ method with the ‘golden standard’ of laparoscopic cholecystectomy. Here we present the results of the first prospective observational study comparing standard laparoscopic cholecystectomy with single-port cholecystectomy as well as transvaginal-hybrid cholecystectomy.     

Performance of COLIA1 Polymorphism and Bone Turnover Markers to Identify Postmenopausal Women with Prevalent Vertebral Fractures

Some studies have suggested that bone turnover markers (BTM) and collagen type I alpha 1 gene (COLIA1) may be useful in the prediction of rates of future bone loss, and may therefore provide information about fracture risk. Our study aimed to examine the association of the COLIA1 genotype with the risk of vertebral fracture and to investigate the predictive value of this genetic factor in comparison with bone mineral density (BMD) and BTM, in ambulatory postmenopausal Spanish women. We determined the COLIA1 polymorphism by polymerase chain reaction, BMD by dual-energy X-ray absorptiometry and BTM in 43 postmenopausal women with prevalent vertebral fracture and a control group of 101 postmenopausal women without fracture. There was a significant overrepresentation of the ‘T’ allele in fractured women (p= 0.029). BTM exhibited no differences between women with or without fractures or COLIA1 genotype groups. After adjusting for all other variables, the osteoporosis densitometric criteria variable was the most strongly associated with fracture (OR = 5 [1.8–13.3]) followed by COLIA1 (OR = 2.1 [1–4.3] per copy of the ‘T’ allele). Our study shows that COLIA1 is associated with prevalent vertebral fracture independently of bone mass, and the performance of this genetic factor to assess prevalent vertebral fracture is better than bone turnover markers. Received: 29 June 2001 / Accepted: 11 December 2001     

Pathomorphological and quantitative bacteriological findings in various forms of primary surgery on gunshot wounds of extremities

It is well-known that ‘wound excision’ is essential in the primary treatment of wounds in war, particularly thorough debridement of the devitalized tissues around the path of a penetrating projectile. Nowadays, the gunshot wounds in peacetime have become prevalent. Instead of the traditional method of ‘wound excision’ (excision), we used the method of ‘incision and drainage’ (incision) in the primary surgery of these gunshot wounds of extremities. To determine the treatment effectiveness of these different surgical methods (incision and excision), two groups of dogs were shot in the proximal part of one hind leg with an American M-16 rifle. One group was treated by the method of ‘excision’; in the other group ‘incision’ were performed. No difference in infection rate was noted between the two groups. Similarly, no difference in bacterial count was found between the two groups during the observation period. Also, there was no difference in healing time; the wounds in both groups had healed by 19.2–21.4 days. Microscopic examination revealed a little normal muscle tissue in the necrotic zone of the incision group which might augment the repair process. These results suggest that there are no differences in the effectiveness in preventing infection between the two methods. ‘Incision’ might be superior to ‘excision’ for the management of the gunshot wounds of extremities in peacetime, as it involves a simple operation and there are advantages for tissue healing. Received: 5 October 2000     

Does caesarean section negatively influence the post-partum prognosis of low back pain and pelvic pain during pregnancy?

Low back and pelvic pain (LBPP) is prevalent during pregnancy and also post-partum. The aetiology is poorly understood. The aim of this study was to investigate possible associations between epidural or spinal anaesthesia and caesarean section (CS) with persistent LBPP half a year after pregnancy. In a previous questionnaire study (n=891) altogether 639 (72%) women had reported LBPP during pregnancy. We sent these respondents a second questionnaire at approximately 6 months post-delivery. The response rate was 72.6% (n=464). The respondents were divided into three groups reporting ‘no pain’, ‘recurrent pain’ and ‘continuous pain’ in relation to LBPP 6 months after delivery. Pearson’s chi-square test was used to test the difference between groups and logistic regression analysis was performed. Forty percent of the respondents had received epidural anaesthesia (EDA) or spinal anaesthesia during delivery and 18.5% of women had been delivered by CS. Epidural or spinal anaesthesia was not associated with persistent LBPP. There was no significant difference in CS rates between different sub-groups. The risk of persistent LBPP was increased three- to fourfold in women delivered by elective CS compared with women delivered by emergency CS. Epidural or spinal anaesthesia was not associated with risk of persistent LBPP. Elective CS was associated with an increased risk of persistent LBPP. However, the results must be interpreted with caution because of a relatively small study sample.     

New Approach in Surgical Treatment of Morbid Obesity: Laparoscopic Gastric Banding

Background: gastric banding has been performed for morbid obesity, with the last nine patients having a laparoscopic approach. Materials: forty-five patients who had undergone primary operations for morbid obesity between 1986 and 1993 were selected for retrospective analysis. All patients had undergone gastric banding. Average pre-operative BMI was 50.9 (kg m⁻²) and average pre-operative weight was 135.1 kg. Results: the 3-year mean post-operative BMI reached 28.7 and the 3-year mean post-operative weight loss was 55.7 kg. Blood pressure significantly decreased from the mean 151/96 mmHg to 132/90 mmHg at 1-year follow-up. There were no significant changes noted in the levels of RBC, electrolytes and transaminase. There were post-operative wound-healing complications in 18.1% of the patients, wound discharge in 8.8% and incisional hernia in 8.8% of the patients. In 1993 we commenced laparoscopic gastric banding which enabled us to shorten the hospital stay and decrease post-operative complications. Conclusion: we are achieving the same good weight-loss results with the laparoscopic technique as after ‘open’ laparotomy gastric banding.     

The Presence and Severity of Vertebral Fractures is Associated with the Presence of Esophageal Hiatal Hernia in Postmenopausal Women

We examined the relationship between the presence of esophageal hiatal hernia (HH) assessed by endoscopy and the presence of vertebral fractures (VFs) in 87 Japanese postmenopausal women (age range 52–87 years). We found that 29 (63%) of 46 patients with HH (71.2 ± 6.1 years, mean ± SD) had one or more VFs, compared with 14 (34%) of 41 patients without HH (70.8 ± 6.8 years), which was a significant difference in the frequency of VFs (c²= 7.242; p= 0.0071). The average number of VFs per patient was significantly higher for the patients with HH than for those without HH (1.67 ± 1.75 vs 0.68 ± 1.21, p= 0.0032). There were no significant differences in absolute or age-matched bone mineral density (BMD) values at the lumbar spine (0.656 ± 0.131 vs 0.662 ± 0.148 g/cm²; Z-score, –0.35 ± 1.17 vs –0.26 ± 1.00) and there were no significant differences in biochemical parameters, age, years since menopause or body mass index (BMI) between the two groups. When patients were divided into those with reflux esophagitis (RE) (n= 30, 70.2 ± 7.3 years) and those without RE (n= 57, 71.4 ± 5.9 years), no significant differences were detected in any of the above parameters including the presence or number of VFs. The patients were further subdivided into four groups: those with ‘HH only’ (n= 23, 72.3 ± 4.6 years), with ‘RE only’ (n= 7, 70.9 ± 7.7 years), with ‘both’ (n= 23, 70.0 ± 7.3 years) and with ‘neither’ (n= 34, 70.8 ± 6.7 years). One or more VFs were found in 12 (52%), 1 (14%), 17 (74%), and 13 (38%) patients in each group, respectively, and the difference in frequency was significant (c²= 10.748; p= 0.0132). The average number of VFs per patient in each group was 1.57 ± 2.06, 0.14 ± 0.38, 1.78 ± 1.41 and 0.79 ± 1.30, respectively, and there were significant differences between the ‘both’ and ‘neither’ groups, and between the ‘both’ and ‘RE only’ groups (p<0.05). When univariate logistic regression analysis was performed with the presence of HH as a dependent variable and each of the presence of VFs, the number of VFs per patient, absolute or age-matched BMD values at the lumbar spine, BMI and plasma albumin as independent variables, the presence of VFs and the number of VFs per patient were selected as indices affecting the presence of HH (odds ratio: 3.29 and 1.59, 95% confidence interval: 1.36–7.94 and 1.14–2.23; p = 0.0080 and 0.0064, respectively). These results show that the presence and severity of VFs are associated with the presence of HH but not of RE in Japanese postmenopausal women, and suggest that kyphosis induced by multiple VFs might predispose elderly women to a complication with HH. Received: 2 March 2001 / Accepted: 11 June 2001     

Bedsores: “top to bottom” and “bottom to top”

Bedsore is a global problem concerning the bedridden, infirm, debilitated and malnourished patients in hospitals and community setups. The cost of treatment is enormous involving billions of dollars to nations and individuals. Mortality increases two to six times if bedsores are present. There is little research done despite its commonness to understand how they occur or why they occur; etiology is not much understood. The two theories called ‘top to bottom’ and ‘bottom to top’ contradict each other. It is thought that ‘pressure’, shear-stress’ and ‘ischemia’ may be causing it in some yet to be understood way. There is little awareness on how to prevent them or how to treat them if they do occur. Seldom applied, various scales exist and should be used to identify patients at high risk. Braden scale is the most tested and widely accepted scale. The various available dressings and pressure relief devices are mostly inadequately studied; which is superior is a question that begs an answer. This article aims to underline the importance of bedsores by reviewing our current and past knowledge with emphasis on practical implications thereof.     

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis: results of Swanson implants and digital joint operative arthroplasty

We discuss 69 metacarpophalangeal (MP) implant arthroplasties performed in 30 patients with rheumatoid arthritis. The follow-up averaged 5 years. We studied 19 finger joint prostheses by Condamine, digital joint operative arthroplasty (stabilized version; DJOA) and 50 flexible silicone Swanson implants. We used a new comprehensive scoring system to evaluate the MP alloarthroplasties. Such a scoring system incorporates clinical and radiological data. The outcome following MP joint replacement with DJOA was never evaluated as ‘good’; in 11 joints the result was ‘fair’, and in 8 joints, ‘poor’. As regards MP arthroplasty with Swanson implants, the results were evaluated as ‘good’ in 40 joints, as ‘fair’ in 10 joints, and in none as ‘poor’. In our series, DJOA did not provide stability in arthritic MP joints. In all joints replaced with DJOA, dislocation of the articulating surfaces and signs of loosening were present. We regard three factors as being the main causes contributing to the poor outcome of DJOA when used as MP replacements. Firstly, the proximal prosthetic component is poorly matched to the anatomical shape of the metacarpal bone (conisation of the bone). Secondly, adequate coaptation cannot be achieved with this prosthetic design, even in the presence of extensive soft-tissue reconstruction. Thirdly, the use of polyethylene in MP joint replacements is questionable. In contrast, the silicone Swanson implants in our series provided superior results when used as MP implants in the rheumatoid hand. Received: 13 March 1998     

A Decade of Change in Obesity Surgery

Background: The International (formerly National) Bariatric Surgery Registry began collecting data in January 1986. The aim of this study was to examine changes in the practice of surgical treatment of severe obesity that occurred during the decade of 1986 through 1995, as observed in the IBSR data. Methods: All data submitted to the IBSR during the decade were transferred to the IBM mainframe computer for analysis. Characteristics of operative type populations were compared over time using analysis of variance (ANOVA) for age, body mass index (BMI), operative weight and Chi-square (χ²) test for gender. Results: There has been a steady increase over the decade in mean patient weight. The operations used have changed from predominantly ‘simple’ operations to more frequent use of ‘complex’ operations. Within the categories of ‘simple’ and ‘complex’, an increase in the variety of operations occurred. As a group, patients with ‘simple’ operations have been heavier, more often male and public pay patients than those who have undergone ‘complex’ operations. One year weight loss was greater for Roux-en-Y gastric bypass (RGB) than vertical banded gastroplasty (VBG), but follow-up rates were too low to study the relative merits of the operations used. The reported incidence of operative mortality and serious complications (leak with peritonitis, abscess and pulmonary embolism) remained low. Conclusions: These observations and their implications can be summarized in three statements which relate to action for improved patient care in the beginning of the new century: (1) increasing weight of candidates for surgical treatment during this decade indicates the need for earlier use of operative treatment before irreversible complications of obesity can develop; (2) low risk of obesity surgery, decreasing postoperative hospital stay, and early weight control support the continued and increased use of surgical treatment; (3) continued widespread use of both ‘simple’ and ‘complex’ operations with increased modifications of standard RGB and VBG procedures emphasizes the need for standardized long-term data and analyses regarding both weight control and postoperative side-effects.