血吸虫病肝硬变伴症状性胆结石患者腹腔镜胆囊切除

目的 探讨血吸虫病肝硬化伴症状性胆结石患者腹腔镜胆囊切除(LC)的效果。方法 回顾性分析4年来我院血吸虫病性肝硬化伴胆囊结石行胆囊切除术265例的临床资料。行LC的74例，与常规开腹手术(OC)组进行对比，比较两组术中出血量、手术时间、住院时间、并发症、术后恢复情况等。结果 手术平均时间LC组为63min，OC组为53min；平均术后住院时间LC组为1．2d，OC组为8．9d；平均手术出血量LC组为15．6ml，OC组为85ml；LC组中转手术6例(8．1％)，无1例发生并发症；OC组术后胆漏1例。结论 血吸虫病性肝硬化胆结石患者只要严格掌握腹腔镜手术适应证，采取正确的手术操作方法，LC是安全可行的。     

腹腔镜胆囊切除联合阑尾切除130例

目的 探讨腹腔镜胆囊切除(LC)同时行阑尾切除术的可行性。方法 对胆囊结石、胆囊炎合并有急慢性阑尾炎l30例患者，在行腹腔镜胆囊切除术同时行腹腔镜阑尾切除术(LA)。结果 129例成功，1例中转开腹手术。术后无并发症发生。结论 对胆囊结石、胆囊炎合并有急慢性阑尾炎患者可行LC联合LA。LC加LA充分体现了腹腔镜手术的优越性，有推广使用的价值。     

A Prospective Evaluation of Intracorporeal Laparoscopic Small Bowel Anastomosis during Gastric Bypass

Background: We evaluated the safety and feasibility of performing a laparoscopic intracorporeal end-toside small bowel anastomosis using a stapling technique as part of a Roux-en-Y gastric bypass operation (RYGBP). Methods: 80 consecutive patients who underwent RYGBP with laparoscopic jejunojejunostomy were evaluated. Operative time and intraoperative and postoperative complications directly related to the jejunojejunostomy anastomosis were recorded. Results: All 80 laparoscopic jejunojejunostomy procedures were successfully performed without conversion to laparotomy. Mean operative time was longer for the first 40 laparoscopic RYGBP than for the last 40 RYGBP (32±18 min vs 21±14 min, respectively, p<0.05). Intraoperative complications were staple-line bleeding (2 patients) and narrowing of the anastomosis (1 patient). Postoperative complications were four small bowel obstructions: technical narrowing at jejunojejunostomy site (2 patients), angulation of the afferent limb (1 patient), and food impaction at the jejunojejunostomy anastomosis (1 patient). These four patients underwent successful laparoscopic re-exploration and creation of another jejunojejunostomy proximal to the original anastomosis. There were no small bowel anastomotic leaks. The median time to resuming oral diet was 2 days. Conclusions: Laparoscopic jejunojejunostomy as part of the RYGBP operation is a safe and technically feasible procedure. Postoperative small bowel obstruction is a potential complication, which can be prevented by avoiding technical narrowing of the afferent limb.     

Results of the Italian multicenter study on 239 super-obese patients treated by adjustable gastric banding

Background: Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric operation. This study is a retrospective analysis of the multicenter Italian experience in patients with BMI >50 over the last 4 years. Methods: An electronic data sheet made for LAGBoperated patients since January 1996, was mailed and e-mailed to all surgeons involved in this kind of procedure in Italy. Items regarding patients with BMI >50 were selected. Analysis used Fisher's exact test and logarithmic regression analysis (P<0.05 significant). Data were expressed as mean ± SD. Results: 239 patients (13.3%), out of 1,797 LapBand^? operated patients entered the study (179F / 60M), with mean age 37.6±11.3 years (19-69) and mean BMI 54.6±4.8 (50.1-83.6). Laparotomic conversion rate was 5.4% (44/239). Postoperative complications occurred in 24 / 239 patients (9.0%). Follow-up was obtained in 218 / 218, 198 / 198, 121 / 147, 75 / 93, 30 / 38 LAGB patients at 6, 12, 24, 36, and 48 months respectively. At these time periods, mean BMI was 46.7, 43.9, 42.2, 41.9, and 39.3 kg/m². At the same intervals, mean %EWL was 24.1, 34.1, 38.8, 38.9, and 52.9%.The number of patients with <25% EWL at 12, 24, 36, and 48 months follow-up were 34, 10, 4, and 0. Serious co-morbidities (189 in 124 of 239, 57%) had completely resolved 1 year postoperatively in 74 / 124 of the patients (59.6%). Conclusion: Although super-obese patients following the LAGB remain obese with BMI >35, in the short-term most lose their co-morbidities, with a very low morbidity and mortality rate.     

Laparoscopic Silicone Adjustable Gastric Band; Initial Experience in Finland

Background: The Swedish adjustable gastric band (SAGB) was introduced in 1985 and rapidly gained popularity.Today more than 21,000 gastric banding procedures have been performed in Europe. The reported results of gastric banding operations are mainly good, although the method is not without controversies and risks. We report here our initial experience with the SAGB. Methods: 60 patients (44 women, 16 men) were treated surgically for morbid obesity between the years 1996 and 1999, with SAGB. Median age of the patients was 44 years (range 21-64) and preoperative median Body Mass Index (BMI, kg/m2) was 45 (range 35-55). 3 patients were operated by an open approach, and the remaining 57 laparoscopically. Results:Operative time was 62-206 minutes (median 97 minutes). Only one operation was converted to open approach (1.8%), due to extensive adhesions. No intraoperative complications occurred. At 1 year follow-up, mean weight loss was 30 kg, mean excess weight loss was 50%, and median BMI was 35. 4 patients have been reoperated so far (6.7%) due to slippage of the band (2 patients), infection of the band (1 patient), and leaking of the filling system (1 patient). Median postoperative hospital stay was 3 days (range 2-53). Mortality was 0%. Immediate postoperative mor- bidity-rate was 12% (7/60), although serious morbidity occurred in only 1 patient (1.7%). Conclusions: Laparoscopically placed adjustable gastric band is a good option for the morbidly obese patient.     

An Alternative Technique for Creating the Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass: Experience with 28 consecutive patients

Background:This study illustrates our experience in laparoscopic Roux-en-Y gastric bypass (LRYGBP) using a new technique for creating the gastrojejunostomy. Methods: Between April and November 1999, 28 patients underwent LRYGBP. In the first 10 patients the transoral route with endoscopic guidance was utilized for placement of the anvil in the gastric pouch. A new totally intra-peritoneal approach was utilized in the next 18 patients, avoiding the transoral route. Results:There were 23 women and 5 men with an average age of 36 years (range 24-51). The mean BMI was 47, with range 41-64. Of the patients, 82% had one or more associated co-morbid conditions (hypertension, diabetes, sleep apnea, arthritis). Average operative time in the first 10 patients using the trans-oral route with endoscopic guidance was 340 minutes (range 240-390 min). The next 18 patients underwent totally intra-peritoneal anvil placement with a 240-minute average operating time (range 150-310 min). There were no open conversions or mortalities.There were 4 complications, including 2 wound infections, one urinary tract infection, and one intra-abdominal abscess. The two wound infections occurred in the first 10 patients that underwent trans-oral introduction of the anvil. Conclusions: LRYGBP was a safe and feasible operation. We believe that our technique is easily reproducible, avoiding the trans-oral route for introducing the anvil. This technique may also decrease operative time and possibly the incidence of wound infections, although we are still in the learning curve and final conclusions cannot be made.     

Open vs Laparoscopic Vertical Banded Gastroplasty: A case control study with 1-year follow-up

Background: Vertical Banded Gastroplasty (VBG) is one of the most common bariatric operations. It can be performed by open or laparoscopic methods. The purpose of this study was to analyze and compare the 1-year results of 40 patients who underwent laparoscopic (20) and open (20). Methods: The initial 20 patients undergoing LaparoscopicVBG and the initial 20 patients in whom an Open VBG were performed in our Institution were comparatively evaluated. Demography, surgical details, complications, and 1-year weight loss were analyzed. Results: Both groups were highly comparable in terms of age, sex and body mass index. Laparoscopic VBG was a more prolonged procedure (median 4 hr) than the open VBG (median 3 hr). On the other hand, hospital stay was significantly shorter in the laparoscopic procedure (median 10 days for the open and 6 days for the laparoscopic). One year weight loss and complications were similar in both groups. Conclusions: Laparoscopic VBG is a safe procedure for the treatment of morbid obesity. This initial series shows comparable results.     

Early Results of Laparoscopic Biliopancreatic Diversion with Duodenal Switch: A Case Series of 40 Consecutive Patients

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure.We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity. Methods: A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months. Results: 40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 ± 1 years (± SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 ± 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3- 210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% ± 2% excess weight loss (EWL) and at 9 months 58% ± 3% EWL. Conclusion: Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.     

腹腔镜胃急性穿孔修补术

目的 总结腹腔镜胃穿孔修补术的治疗效果。方法 在气管插管、静脉麻醉下，应用腹腔镜对46例胃溃疡急性穿孔，经病理检查后，行穿孔修补、腹腔引流术。结果 46例胃穿孔中，幽门管穿孔6例，实部前壁穿孔37例，体部小弯侧穿孔3例：快速病理检查33例中良性穿孔32例，癌性穿孔1例。手术均成功，无中转手术和手术并发症及死亡。45例良性溃疡患者术后7d出院3l例，转消化内科治疗2周后出院14例，出院后继续抗溃疡治疗3个月后复A45例，临床症状全部消失，饮食基本止常，体重增加1～3kg。3个月后胃镜检查活榆报告：未见恶性肿瘤细胞。癌性穿孔1例，拒绝进一步治疗，于修补术后9d出院。结论 腹腔镜肖穿孔修补术不违反外科手术原则，术中病理检查可预防漏诊胃恶性肿瘤。该手术创伤小，恢复快，术后并发症少，安全可靠，值得推广应用。     

Laparoscopic Vertical Banded Gastroplasty: 5-year Results

Background:Vertical banded gastroplasty (VBG) has been a popular bariatric operation for the past 2 decades, and this operation has evolved into a laparoscopic procedure. However, reports of laparoscopic VBG (LVBG) from large series with longer results are limited. Methods: From October 1998 to May 2002, 612 consecutive patients underwent LVBG. Mean age was 30.1 years and mean BMI 43.0 kg/m². Laparoscopic Mason gastroplasty was performed. The change of BMI, obesity-related co-morbidities, and GI quality-of-life index (GIQLI) were studied. Results: The major and minor complication-rate was 1.14% and 4.58% respectively. The mortality-rate was 0.16%. Mean BMI fell from 43.1 kg/m² to 31.2, 31.3, 31.4, 32.2, and 32.8 kg/m² at 1, 2, 3, 4, and 5 years respectively, with 93% follow-up. Revision rate was 9.2%. GIQLI decreased from 113.0 to 106.6, 110.9, 111.9, 112.1, and 106.4 at 1, 2, 3, 4, and 5 years. Conclusion: LVBG is safe and effective in weight reduction. The GIQLI failed to improve postoperatively even with good resolution of obesity-related co-morbidities. In carefully selected patients with diligent postoperative follow-up, LVBG is a bariatric surgery option.