肝胆管结石再手术原因及处理:附81例报告

目的　探讨肝胆管结石再手术的原因及手术处理方法。方法　回顾性分析 81例肝胆管结石患者的临床资料。再手术的方法主要包括肝叶切除、肝肠Roux en Y盆式内引流、肝叶切除加肝胆管Roux en Y盆式内引流。结果　肝胆管结石再手术的主要原因包括胆管狭窄和结石残留、胆管变异、合并胆管细胞癌等 ,再次手术后经胆道造影证实残留率为 6.2 % ,随访术后病人优良率为93 .8%。结论　清除结石、解除狭窄、矫正崎形、切除病肝、通畅引流系肝胆管结石的治疗原则。     

甲状腺功能亢进症术后复发的再手术治疗:附34例报告

目的 探讨甲状腺功能亢进症(甲亢)术后复发的原因，再手术治疗的适应证及手术方法。方法 回顾性分析34例甲亢术后复发再手术治疗的l临床资料。结果 再次手术术式包括双侧甲状腺次全切除29例，单侧腺叶切除5例。全部治愈。并发症发生率5．9％，与笔者收治的同期甲亢初次手术比较无统计学差异。全组经随访l～l0年，无甲亢再复发或甲状腺功能低下者。结论 腺体残留过多是甲亢术后复发的主要原因，有选择地再手术是甲亢术后复发较好的治疗方法。术中仔细解剖可避免损伤喉返神径和甲状旁腺，以及预防大出血的发生。     

Hand-Assisted Laparoscopic Revision of Previous Restrictive Operations to Vertical Banded Gastroplasty

Background: Revision of failed gastric restrictive procedures to proximal Roux-en-Y gastric bypass (RYGBP) is the standard for many bariatric surgeons. Where the patient is not a suitable candidate or simply refuses gastric bypass, an alternative is herewith proposed. Methods: 3 patients had undergone a gastric banding as the original operation and 1 patient had had a vertical banded gastroplasty (VBG). 1 patient presented with insufficient weight loss, 1 with regain of weight and 2 with complaints of food intolerance and vomiting. The gastric bands were removed by hand-assisted laparoscopy (HALS), with conversion to a VBG. In the patient with stomal stenosis after a VBG, HALS interposition of PTFE was performed to enlarge the collar. Results: In 2 patients, further weight reduction was achieved. In the other 2 patients, relief of symptoms was achieved.There were no complications during or after the revisional surgery. Conclusion: HALS conversion of a gastric banding to a VBG, or PTFE interposition in the case of stomal stenosis after a VBG, can be a valuable alternative for patients unsuitable for or refusing proximal RYGBP.     

Combining Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion after Failed Bariatric Surgery

Background: A percentage of all types of bariatric surgery will fail. Our experience with failed biliopancreatic diversion (BPD) as a primary operation or revision operation for failed laparoscopic adjustable gastric banding (LAGB) convinced us that uncontrolled hunger is often the underlying cause. To control hunger after failed bariatric surgery,a novel approach combining LAGB with BPD-duodenal switch (DS) has been tried. Methods: Patients who had failed to lose weight after BPD or LAGB were considered in 2 groups. Group 1: patients who had failed LAGB underwent laparoscopic BPD-DS without sleeve gastrectomy, with the LAGB left in-situ. Group 2: patients who had failed primary (subgroup 2a) or revision (subgroup 2b) BPD had a LAGB placed with no other revision of their surgery. Results: 11 patients have undergone this form of revision surgery with little morbidity. Mean age at the original operation was 45 years, mean (range) BMI was 45.3 (38-62) kg/m². After the reoperation, at 3 months (9 patients) mean BMI was 30 kg/m² and at 6 months (4 patients) mean BMI was 27 kg/m². Conclusion: In this small study, combination surgery was safe and effective for failed BPD or LAGB. LAGB failure may be best managed with DS malabsorption without gastric resection.     

胆肠吻合术后再手术的原因及处理

目的 探讨胆肠吻合术后再手术的原因及处理方法。方法 回顾性分析1995年6月－1999年6月间28例胆肠吻合术后再手术的临床资料。结果 28例中,吻合口狭窄26例（92．8％）,伴左肝管狭窄9例,肿肝管狭窄3例,左右肝管狭窄5例。钡餐造影9例见胆管内返流,均为胆总管十二指肠吻合者。再手术方法：原吻合口切除再吻合3例,左肝外叶切除、肝门胆管整形与空肠Roux-en-Y吻合8例,左肝管、肝门胆管与空肠双口吻合2例,肝内胆管狭窄切开并整形后与空肠Roux-en-Y吻合15例。26例（92．8％）随访0．5－4年,仅1例（3．8％）间有轻度感染症状。结论 胆肠吻合口狭窄是再手术的根本原因,其次是术式选择不当、肝胆管狭窄未予解除及结石清除不彻底。再手术时应遵循清除结石、解除狭窄及通畅引流的原则,必要时结合肝段（叶）切除、吻合口支撑引流及术中、术后胆道镜处理。     

Current status of non-adjustable gastric banding

Background: The purpose of this study is to review the current status of non-adjustable gastric banding (NGB) and to determine whether this operation is still acceptable in the management of morbid obesity, especially when compared with the adjustable GB (AGB) in long-term results. Materials and Methods: A literature search was conducted of data published on NGB and AGB in Obesity Surgery in the past 12 months or available from other sources, with records of early and late band-related complications, reoperation rate and weight loss in groups reporting ≥100 patients with minimum 3-year postoperative follow-up. Results: 1,812 NGB and 1,968 AGB patients were included. Mean BMI was 42.4 in NGB vs 44.0 in AGB. No statistical difference occurred in the early complication rate (1.4% in NGB vs 1.6% in AGB). A statistical difference was noted in long-term complication rate, (1.9% in NGB vs 6.7% in AGB), and in reoperation rate (3.4% vs 7.2%). There was no difference in excess weight loss at 48 months following both operations (54.2% vs 53.0%). Conclusion: A significant difference in favor of NGB occurred in the long-term reoperation rate. No other differences were identified, other than in band material. NGB is a softer material and therefore, according to computerized images, has greater flexibility in copying gastric peristaltic waves, which may result in less irritation and more physiological behavior by this band.     

Reoperative Laparoscopic Roux-en-Y Gastric Bypass: An Experience with 49 Cases

Background: Long-term complications leading to reoperation after primary bariatric surgery are not uncommon. Reoperations are particularly challenging because of tissue scarring and adhesions related to the first operation. Reoperations must address the complication(s) related to the scarring and, at the same time, prevent weight regain that would inevitably occur after simple reversal. Conversion to Roux-en-Y gastric bypass (RYGBP) has repeatedly been demonstrated to be the procedure of choice in most situations. It has traditionally been performed through an open approach. Our aim is to describe our experience with the laparoscopic approach in reoperations to RYGBP over the past 5 years. Methods: All patients undergoing laparoscopic RYGBP as a reoperation were included in this study. Patients with multiple previous operations or patients with band erosion after gastric banding were submitted to laparotomy. Data were collected prospectively. Results: Between June 1999 and August 2004, 49 patients (44 women, 5 men) underwent laparoscopic reoperative RYGBP. The first operation was gastric banding in 32 and vertical banded gastroplasty in 15. The mean duration of the reoperation was 195 minutes. No conversion to open was necessary. Overall morbidity was 20%, with major complications in 2 patients (4%). Weight loss, or weight maintenance, was satisfactory, with a BMI <35 kg/m² up to 4 years in close to 75% of the patients. Conclusions: Laparoscopic RYGBP can be safely performed as a reoperation in selected patients provided that the surgical expertise is available. These procedures are clearly more difficult than primary operations, as reflected by the long operative time. Overall morbidity and mortality, however, are not different. Long-term results regarding weight loss or weight maintenance are highly satisfactory, and comparable to those obtained after laparoscopic RYGBP as a primary operation.     

Complications after gastroplasty and gastric bypass as a primary operation and as a reoperation

Background: Since 1991 we performed vertical banded gastroplasty (VBG) as our surgical treatment of choice for morbid obesity in 680 patients, and since 1996 we also performed Roux-en-Y gastric bypass (RYGB) in 36 patients. For revisional surgery, the surgeons chose procedures based on their experience. Methods: We recorded early complications (0.6%) and late complications (8.5%) after the primary operations.When staple-line disruption or stenosis of the banded stoma occurred after VBG, revisional surgery was performed with re-VBG or conversion to RYGBP. Some early complications needed emergency operation for bleeding or gastric perforation. Results: Mortality was zero. Reoperation with reVBG and RYGBP was effective in all patients, but for many, a long stay in hospital was necessary because reoperation had a high rate of early and late complications, 33.8% and 21.8% respectively. Conclusion: The treatment of complications after VBG with re-VBG and RYGBP had danger.We believe that when VBG failure occurs, to avoid dangerous complications again, we should perform a biliopancreatic diversion, which does not involve a gastric restriction.     

Duodenal Switch Without Gastric Resection after Failed Gastric Restrictive Surgery for Morbid Obesity

Background: Several surgical treatments have been proposed for patients in whom gastric restrictive operations have failed. The aim of this study was to analyze the effectiveness and safety of duodenal switch (DS) with restoration of normal gastric capacity in such patients. Methods: Between May 2001 and May 2003, 11 DS with restoration of normal gastric capacity were performed without other gastric procedures in patients who had had previous gastric restrictive operations which had failed because of inadequate weight loss or weight regain. Data were collected and follow-up was 2 years for all patients. Results: At the original operation, mean BMI was 47.3 (range 38-53) kg/m², and mean age was 42 years. 7 of the 11 patients (63.6%) had previous vertical banded gastroplasty, and 4 of the 11 (36.4%) had previous laparoscopic adjustable gastric banding. Mean percentage weight regain and mean BMI at the time of DS were 92.1% and 44.6 (range 35-53) kg/m² respectively. After the second operation, mean BMI at 6 months was 35.4 kg/m², at 12 months 31.7 kg/m² and at 24 months 28.6 kg/m². The % excess weight loss was 41.1 after 6 months, 56.6 after 12 months and 69.6 after 2 years. There was minor morbidity and no mortality. Conclusion: After this experience, we suggest that patients with failed gastric restrictive operations (weight regain or inadequate weight loss) may undergo DS with restoration of normal gastric capacity. This second operation proved to be safe and effective.     

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Conclusion: Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.