Pre-operative Weight Loss Does Not Predict Weight Loss Following Laparoscopic Adjustable Gastric Banding

Background

This study aimed to test the hypothesis that the amount of weight lost on a mandatory 2-week pre-operative very-low-calorie diet (VLCD) would predict the longer-term outcomes of laparoscopic adjustable gastric banding (LAGB).

Methods

All patients treated with a primary LAGB from 21 October 2008 until 30 June 2010, who were prescribed a 2-week pre-operative VLCD, have been included in the study. Patient age, weight, BMI and excess weight (defined as weight above a BMI of 25) were extracted on the day of first visit, day of surgery and at the post-operative visits at 3, 12 and 24 months. From these data, percent excess weight loss (EWL) was calculated and compared at all time points.

Results

The weight loss achieved on a mandatory 2-week pre-operative diet did not predict weight outcomes at 2 years (r?=??0.008; p?=?0.931). Using multivariate analysis, the best predictor of 24-month percent EWL was percent EWL at 3 months post operation (sr²?=?0.34; p?=?0.003).

Conclusions

Results from a pre-operative diet should not be used to predict the ultimate outcome of bariatric surgery. The weight loss at 3 months following LAGB was a strong predictor of longer-term outcomes. There may be potential for improving longer-term results with LAGB by better supporting patients who are not achieving good weight loss at this early time point.     

Sleeve Gastrectomy Severe Complications: Is It Always a Reasonable Surgical Option?

Background

Laparoscopic sleeve gastrectomy (LSG) is widely adopted but exposes serious complications.

Methods

A retrospective database analysis was done to study LSG staple line complications in a tertiary referral university center with surgical ICU experienced in treatment of morbid obesity and complications. Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. Interventions consisted in the control of intra-abdominal and general sepsis; restoration of staple line continuity or revision of LSG; nutritional support; treatment of associated complications. Main outcome measures concerned success rates of therapeutic strategies, morbidity and mortality rates, LOS, and time to cure.

Results

Thirteen patients (59 %) were referred after failure of reoperation (seven fistula repairs were attempted). Three patients received emergency surgery in our center with transorificial intubation and jejunostomy formation. An endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1–161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0–1,915 days) for conservative treatment failure. Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %. Mortality rate was 4.5 % (n?=?1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %, p?=?0.003). Median time to cure was 310 days (9–546 days).

Conclusions

LSG exposes severe complications occurring in patients with benign condition. Endoscopic stents entail high failure rate. Total gastrectomy is required in one third of the cases.     

Right Colectomy with Absorbable Mesh Repair as a Salvage Solution for the Management of Giant Incisional Hernia with Loss of Domain: Results of a Bicentric Study

Background

Incisional hernia (IH) may occur in 20% of patients after laparotomy. The hernia sac volume may be of significance, with reintegration of visceral contents potentially leading to repair failure or abdominal compartment syndrome. The present study aimed to evaluate a two-step surgical strategy comprising right colectomy for hernia reduction with synchronous absorbable mesh repair followed by definitive non-absorbable mesh repair in recurrence.

Methods

Patients operated between 2012 and 2017 at two university centers were retrospectively included. Volumetric evaluation of the IH was performed by CT imaging.

Results

Eleven patients were included. The mean BMI was 43 kg/m² (23–52 kg/m²). Progressive preoperative pneumoperitoneum was performed in 82% of patients, with complications in 22%. The mean volumetric ratio of the volume of the hernia to the volume of the abdominal cavity was 70% (48–100%). The first parietal repair was performed using an synthetic absorbable mesh (36%), a biologic mesh (27%), or a slowly absorbable mesh (36%). No patients died as a result of the procedure. Seven (64%) patients developed grade III–IV complications, including one case of an anastomotic fistula. Recurrence occurred in eight (73%) patients after the first repair. Of these, four (50%) patients were reoperated using a non-absorbable mesh, leading to solid repair in 75% of cases. After 27 ± 18 months of follow-up, the residual IH rate was 46%.

Conclusions

Right colectomy for volume reduction in IH with loss of domain potentially represents an appropriate salvage option, supporting bowel reintegration and temporary hernia repair with absorbable material.

     

Über einen Fall von jungem “Ulcuscarcinom” des Magens

Zusammenfassung In einem resezierten Magenstück fand sich an der kleinen Kurvatur ein kronengroßes Ulcus, das makroskopisch sich als typisches Ulcus pepticum callosum darstellte. Auch die ersten, den Grund und die Geschwürsränder umfassenden Schnitte zeigten im mikroskopischen Bild kein Carcinom. Die genauere Untersuchung der Schleimhaut in der Umgebung des Geschwürs ergab, daß sich in der Nähe des Geschwürsrandes ein kaum erbsengroßes Gallertcarcinom entwickelt hat, und daß auf eine größere Fläche hin ein eigentümliches zylindrisches Epithel, das sich durch auffallend dunkle Färbung der Kerne und des Protoplasmas auszeichnet, das normale Oberflächenepithel des Magens in den Grübchen und an der Schleimhautoberfläche verdrängt hat. In die tiefen Schichten der Magenschleimhaut ist das abnorme Epithel nur an wenigen Stellen vorgerückt. Erst bei sorgfältigster Untersuchung gelingt es, vereinzelte Stellen von fortgeschrittener Anaplasie (lumenlose Zellreihen, fehlende Basalmembran) zu finden. Es ist kein Zweifel, daß auch dieses dunkle Epithel carcinomatös ist, vermutlich ein sehr junges Stadium der Carcinomentwicklung. Es wurde den AnsichtenHausers undAschoffs entsprechend reiflich erwogen, ob das Ulcus oder das Carcinom als die primäre Bildung anzusehen sei. Die Entscheidung, daß doch das Ulcus in diesem Falle als das Primäre anzusehen sei, stützt sich darauf, daß der größte Teil des Geschwürsgrundes und ein Teil des Geschwürsrandes frei von Carcinom ist, und der narbige Geschwürsgrund als älter einzuschätzen ist als das offenbar ganz junge Carcinom, dessen größtes Tiefenwachstum überdies außerhalb des Geschwürsbereiches gelegen ist. Der Fall lehrt neuerdings, daß ein Carcinom neben Ulcus callosum nur nach sehr ausgedehnter Untersuchung ausgeschlossen werden kann. Der Befund des beschriebenen dunklen Epithels könnte künftig als Fingerzeig dienen und zu weitergehender Untersuchung, als sie sonst möglich und üblich ist, veranlassen.Mit 10 Textabbildungen.Abgekürzt demonstriert in der Vereinigung der pathologischen Anatomen Wiens am 29. Oktober 1923.     

Comparison of complete versus partial mesh removal for the treatment of chronic mesh infection after abdominal wall hernia repair

Purpose

Treatment of chronic mesh infections (CMI) after parietal repair is difficult and not standardized. Our objective was to present the results of a standardized surgical treatment including maximal infected mesh removal.

Methods

Patients who were referred to our center for chronic mesh infection were analyzed according to CMI risk factors, initial hernia prosthetic cure, CMI characteristics and treatments they received to achieve a cure.

Results

Thirty-four patients (mean age 54?±?13 years; range 23–72), were included. Initial prosthetic cure consisted of 26 incisional hernias and eight groin or umbilical hernias of which 21% were considered potentially contaminated because of three intestinal injuries, two stomas and two strangulated hernias. The mesh was synthetic in all cases. CMI appeared after a mean of 83 days (range 30–6740) and was characterized by chronic leaking in 52 cases (50%), an abscess in 22 cases (21%) and synchronous hernia recurrence in 17 cases (16.5%). Eighty-six reinterventions were necessary, including 36 mesh removals (42%), and 13 intestinal resections for entero-cutaneous fistula (15%). The CMI persistence rate was 81% (35 reinterventions out of 43) when mesh removal was voluntarily limited to infected and/or not incorporated material, but was 44% when mesh removal was voluntarily complete (19 reinterventions out of 43; p?<?0.001). On average, 3.4 interventions (1–11) were necessary to achieve a cure, after 2.8 years (0–6). Fourteen incisional hernia recurrences occurred (41%).

Conclusions

Treatment of chronic mesh infection is lengthy and resource-intensive, with a high risk of hernia recurrence. Maximal mesh removal is mandatory.

     

Intersexualitätslehre und Hermaphroditismus und ihre Bedeutung für die Klinik

Ohne Zusammenfassung