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Background: Laparoscopic adjustable gastric banding is a widely used and effective procedure for the treatment of morbid obesity, but its major complication, the dilatation of the gastric pouch, is reported with a frequency ranging from 1.5 to 26.3%, and often requires removal of the band. With the aim to prevent this complication, we introduced a modified technique in our clinic, over the last 4 years. Methods: From December 1993 to August 2004, 649 morbidly obese patients underwent adjustable gastric banding (AGB), 83 patients in open surgery and 566 patients laparoscopically. The first 323 patients were operated with the perigatric procedure, and 57 patients were operated with the pars flaccida procedure. Since December 2000, 269 patients were operated with a modified technique of the pars flaccida procedure, which consisted in suturing the lesser gastric curvature with one or two stitches to the right crus. Results: In the first group of 323 patients, the most important late complication was the irreversible dilatation of the upper gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5 cases. In the second group of 57 patients, there were 3 pouch dilatations (5.2%) which required replacement. In the last 269 patients operated with the new technique, since December 2000, only 4 dilatations occurred (1.48%), which required 3 band removals and 1 band replacement. Conclusions: A technical modification of the usual procedure appears to considerably reduce the major complication of adjustable gastric banding, the dilatation of the gastric pouch. [ABSTRACT FROM AUTHOR]

Background: The Lap-Band System® is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI ≤ 35. We report the Italian multicentre experience with BMI ≤ 35 kg/m2 over the last 5 years. Patients and Methods: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System®. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI ≤ 35 were selected. Data were expressed as mean ± SD except as otherwise indicated. Results: 225 (6.8%) out of 3,319 Lap-Band® patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19±11.8, range 17-66 years, mean BMI 33.9±1.1, range 25.1-35 kg/m2, mean excess weight 29.5±7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1±2.15, 29.7±2.19, 28.7±3.8, 26.7±4.3, 27.9±3.2, and 28.2±0.9 kg/m2 respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30. Conclusions: Although surgical indications for BMI ≤ 35 remain questionable, the Lap-Band® in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate. [ABSTRACT FROM AUTHOR]

Background: An increasing number of surgeons with different levels of experience with laparoscopic surgery and open obesity surgery have started to perform laparoscopic implantation of the Lap-Band®. Methods: An electronic patient data sheet was created and was mailed and e-mailed to all surgeons performing laparoscopic adjustable silicone gastric banding (LASGB) in Italy. Patients were recruited since January 1996. Data on 1,265 Lap-Band System® operated patients (258 M / 1,007 F; mean BMI 44.1, range 27.0-78.1; mean age 38, range 17-74 years) were collected from 23 surgeons performing this operation. Results: Intra-operative mortality was absent. Post-operative mortality was 0.55% (7 patients) for causes not specifically related to LASGB implantation. The laparotomic conversion rate was 1.7% (22 patients). LASGB related complications occured in 143 patients (11.3%). Pouch dilatation was diagnosed in 65 (5.2%), and 28 (2.2%) of these underwent re-operation. Band erosion was observed in 24 patients (1.9%). Port or connecting tube-port complications occurred in 54 patients (4.2%), 12 of whom required revision under general anesthesia. Follow-up was obtained at 6, 12, 18, 24, 36 and 48 months, and mean BMI was respectively 38.4, 35.1, 33.1, 30.2, 32.1 and 31.5. The percentage of patients observed at each follow-up was >60%. There was no intra-operative mortality and no complication-related mortality, with acceptable weight loss. Conclusion: The LASGB operation is safe and effective, and deserves wider use for treatment of morbid obesity. [ABSTRACT FROM AUTHOR]

Objective: Lifestyle modifications and pharmacological interventions can prevent type 2 diabetes in obese subjects with impaired glucose tolerance. The aim of this study was to compare laparoscopic adjustable gastric banding (LAGB) and conventional diet (No-LAGB) in the prevention (primary intervention study; 56 vs. 29 patients) and remission (secondary intervention study; 17 vs. 20 patients) of type 2 diabetes and hypertension in grade 3 obesity in a 4-year study., Research Design and Methods: The subjects (n = 122; age 48.5 +/- 1.05 years; BMI 45.7 +/- 0.67 kg/m2) underwent a diagnostic workup, including psychological and psychiatric assessments, in preparation for the LAGB procedure. Of the 122 subjects, 73 had the surgery (LAGB group). The control group (No-LAGB group) consisted of the 49 subjects who refused the surgery but agreed to be followed up; 6 of these subjects dropped out by the 2nd year of the study, so that the final number of patients was 73 and 43 in the LAGB and No-LAGB groups, respectively. All patients had a yearly visit and oral glucose tolerance test., Results: From baseline to the end of the 4-year follow-up, BMI decreased from 45.9 +/- 0.89 at baseline to 37.7 +/- 0.71 kg/m2 in the LAGB group and remained steady in the No-LAGB group (from 45.2 +/- 1.04 to 46.5 +/- 1.37 kg/m2), with no significant differences between the primary and secondary intervention groups. In the primary intervention study, five of the No-LAGB subjects (17.2%) and none of the LAGB subjects (0.0%; P = 0.0001) progressed to type 2 diabetes; in the secondary intervention study, type 2 diabetes remitted in one No-LAGB patient (4.0%) and seven LAGB patients (45.0%; P = 0.0052). Hypertension occurred in 11 No-LAGB patients (25.6%) and 1 LAGB patient (1.4%; P = 0.0001) and remitted in 1 No-LAGB (2.3%) and 15 LAGB patients (20.5%; P = 0.0001). A study of body mass composition revealed a significant reduction of fat mass and a transitory, but not significant, decrease of fat-free mass in LAGB patients., Conclusions: In morbid obesity, sustained and long-lasting weight loss obtained through LAGB prevents the occurrence of type 2 diabetes and hypertension and decreases the prevalence of these disorders.

Background/aims: The BioEnterics Intragrastric Balloon (BIB, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity., Methodology: Since March 1998, 349 BIB were placed in 303 obese and morbidly obese patients; 95 patients were male and 208 female; mean age was 41.5 years (19-70); mean weight was 118.8 Kg (67-229); mean BMI was 42 Kg/m2, % excess weight was 62.3% (4.6-216.3). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 Kcal/day., Results: After 4 months of balloon treatment, the mean weight loss was 13.9 Kg and the mean reduction in BMI was 4.8 Kg/m2. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes., Conclusions: The best indications for BIB were: morbidly obese (BMI >40) and super-obese patients (BMI >50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbidity in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI <30 only in a multidisciplinary approach.

Background: The Lap Band system procedure is currently the most common bariatric surgical procedure worldwide. This is an interim report of the experience of the 27 Italian centers participating in the national collaborative study group for Lap Band (GILB)., Methods: An electronic database was specifically created. It was mailed and e-mailed to all of the surgeons now performing the laparoscopic gastric banding operation in Italy., Results: Beginning in January 1996, 1893 patients were recruited for the study. There were 1534 women and 359 men with a mean body mass index (BMI) of (range 30.4-83.6) and a mean age of 37.8 +/- 10.9 years (range; 17-74). The mortality rate has been 0.53% (n = 10), mainly due to cardiovascular complications (myocardial infarction, pulmonary embolism). The laparotomic conversion rate has been 3.1% (59/1893) and was higher in superobese patients (BMI>50) than in to morbidly obese patients (BMI <50) (p <0.05). Postoperative complications occurred in 193 patients (10.2%), including tube port failure (n = 79; 40.9%), gastric pouch dilation (GPD) (n = 93; 48.9%), and gastric erosion (n = 21, 10.8%). Most GPD (65.5%) occurred during the first 50 patients treated at each center. The incidence of GPD decreased as the surgeons acquired more experience. Surgery for complications was often performed by laparoscopic access, rarely via laparotomy. No death was recorded as a consequence of surgery to treat complications. Weight loss has been evaluated at the following intervals: 6, 12, 24, 36, 48, 60, and 72 months, with BMI 37.9, 33.7, 34.8, 34.1, 32.7, 34.8, and 32., Conclusions: The Lap Band system procedure has a very low mortality rate and a low morbidity rate and it yields satisfactory weight loss. Surgery for complications can be performed safely via laparoscopic access.

Three cases of biliary tract serious lesions during videolaparoscopic cholecystectomy are reported. They were executed in other hospitals and presented big technical restoring difficulties, not easily resolvable. In 2 cases of lithiasic cholecystitis there was a complete damage of common biliary duct, in the third one there was a double main biliary duct binding with removal of a biliary tract segment. In all cases a biliary confluence-jejunal anastomosis with Roux en y loop was made up. In all cases the operation was difficult because of main bile duct fragility and modest expansion. In the third one the presence of a secondary biliary duct in gallbladder fossa not recognized but drained outside with a common drainage placed during the operation has prevented appearance of jaundice with dilatation of biliary ducts. It has heavily conditioned confluence-jejunal anastomosis with Roux en Y loop. In all cases tubes were left in the biliary duct for few months in order to calibrate it. In 2 patients postoperative course was characterized by the appearance of an external biliary fistula which has spontaneously disappeared. One year later both patients don't present any stenosis or cholangitis problem.

Two cases of biliary tract serious lesions during videolaparoscopic cholecystectomy are reported. In the first case of lithiasic cholecystitis there had been a complete damage of the common biliary duct; in the second case there had been a double main biliary duct binding with removal of a biliary tract segment. In both cases a biliary confluence-jejunal anastomosis with Roux-en-Y loop was made up. In the first one the operation was difficult because of the main bile duct's fragility and modest expansion. In the second one the presence of a secondary biliary duct in gallbladder fossa not recognized, but drained outside with a common drainage placed during the operation prevented appearance of jaundice with dilatation of biliary ducts. It was heavily conditioned performing confluence-jejunal anastomosis with Roux-en-Y loop. The post-operative course was characterized by appearance of an external biliary fistula which has spontaneously disappeared. One year later, neither of the two patients had any stenosis or cholangitis problems.

The authors present their experience at the Centre for the surgical treatment of morbid obesity at Milano University where since 1974, 603 obese patients underwent surgery: 312 jejuno-ileal bypass (JIB), 70 bilio-intestinal bypass (BIB), 102 horizontal gastroplasties (HGP), 44 silastic ring vertical gastroplasties (SRVGP) and 75 adjustable silastic gastric banding (ASGB). Average follow-up for these procedures is 16, 6, 11, 4 years and 24 months respectively. Weight loss is satisfactory in all cases even though the percentages vary in the different procedures. The most serious complications (severe hepatic failure, oxalic interstitial nephritis, persisting malabsorption) occurred in patients submitted to JIB. The best clinical outcome with the lowest complications rate was obtained with BIB compared to other intestinal bypasses. The most frequent complication observed in patients submitted to gastroplasties was incoercible vomiting while the most severe complications were diffuse peritonitis, secondary to gastric perforation, and peripheric neuropathy. Our experience confirms that surgical treatment of morbid obesity refractory to medical therapy is today a safe and effective treatment. BIB has still a role in super-obese young patients (BMI over 50) refusing dietary restriction lifetime. The gastric procedures, especially laparoscopic ASGB, seem to be the best option. The excellent outcome of bariatric surgery can be obtained only in specialized centers where various specialists work together.

Background/aims: We studied the effectiveness of ultrasonography in evaluating the cervical esophagus for the presence of large masses arising from the esophageal wall and consequently, the modifications of the visceral lumen., Materials and Methods: The cervical esophagus can be evaluated by ultrasound with longitudinal and axial scans, using the left thyroid lobe as an acoustic window. The cervical esophagus can be visualized from the C5 to D2 vertebrae. From November 1992 to July 1996, 220 patients with esophageal cancer and 120 subjects without esophageal disease (control group) were examined with ultrasonography. Examination of the cervical esophagus was performed with a linear high definition small parts probe with a frequency of 7.5-10 Mhz., Results: In all 31 patients with cancer of the cervical esophagus, ultrasonography of the cervical region showed the presence of an expanding mass from the esophageal wall as well as the modifications in the visceral lumen. The neoplasm of the cervical esophagus was visualized when its diameter exceeded 5 mm., Conclusions: The experience of the authors shows that, during ultrasound examination of the cervical region, it is possible to accurately evaluate the cervical esophagus, either morphologically or functionally.

The optimal treatment for recurrent stones of the biliary tract in patients previously treated by hepatic-jejunal anastomosis with Roux en Y loop is debated and the criteria are not fully defined. Age, cardiopulmonary diseases, diabetes, multiple previous surgery of the biliary tract, size, number, and type of stones are some of the factors to evaluate before choosing the most convenient approach. We present two high surgical risk patients with recurrent biliary tract stones previously treated with hepatic-jejunal anastomosis and Roux en Y loop, and treated successfully. Percutaneous lithotripsy was used and in one extracorporeal lithotripsy was associated. These techniques offered a good treatment for these patients, but we must consider the high cost of these procedures. The criteria to choose the best option should consider the risk factors and the cost effectiveness of the various possibilities.

The copper(I) and copper(II) complexes with the nitrogen donor ligands bis[(1-methylbenzimidazol-2-yl)methyl]amine (1-BB), bis[2-(1-methylbenzimidazol-2-yl)ethyl]amine (2-BB), N-acetyl-2-BB (AcBB), and tris[2-(1-methylbenzimidazol-2-yl)ethyl]nitromethane (TB) have been studied as models for copper nitrite reductase. The copper(II) complexes form adducts with nitrite and azide that have been isolated and characterized. The Cu(II)-(1-BB) and Cu(II)-AcBB complexes are basically four-coordinated with weak axial interaction by solvent or counterion molecules, whereas the Cu(II)-(2-BB) and Cu(II)-TB complexes prefer to assume five-coordinate structures. A series of solid state structures of Cu(II)-(1-BB) and -(2-BB) complexes have been determined. [Cu(1-BB)(DMSO-O)(2)](ClO(4))(2): triclinic, P&onemacr; (No. 2), a = 9.400(1) Å, b = 10.494(2) Å, c = 16.760(2) Å, alpha = 96.67(1) degrees, beta = 97.10(1) degrees, gamma = 108.45(1) degrees, V = 1534.8(5) Å(3), Z = 2, number of unique data [I >/= 3sigma(I)] = 4438, number of refined parameters = 388, R = 0.058. [Cu(1-BB)(DMSO-O)(2)](BF(4))(2): triclinic, P&onemacr; (No. 2), a = 9.304(5) Å, b = 10.428(4) Å, c = 16.834(8) Å, alpha = 96.85(3) degrees, beta = 97.25(3) degrees, gamma = 108.21(2) degrees, V = 1517(1) Å(3), Z = 2, number of unique data [I >/= 2sigma(I)] = 3388, number of refined parameters = 397, R = 0.075. [Cu(1-BB)(DMSO-O)(NO(2))](ClO(4)): triclinic, P&onemacr; (No. 2), a = 7.533(2) Å, b = 8.936(1) Å, c = 19.168(2) Å, alpha = 97.66(1) degrees, beta = 98.62(1) degrees, gamma = 101.06(1) degrees, V = 1234.4(7) Å(3), Z = 2, number of unique data [I >/= 2sigma(I)] = 3426, number of refined parameters = 325, R = 0.081. [Cu(2-BB)(MeOH)(ClO(4))](ClO(4)): triclinic, P&onemacr; (No. 2), a = 8.493(3) Å, b = 10.846(7) Å, c = 14.484(5) Å, alpha = 93.71(4) degrees, beta = 103.13(3) degrees, gamma = 100.61(4) degrees, V = 1270(1) Å(3), Z = 2, number of unique data [I>/= 2sigma(I)] = 2612, number of refined parameters = 352, R = 0.073. [Cu(2-BB)(N(3))](ClO(4)): monoclinic, P2(1)/n (No. 14), a = 12.024(3) Å, b = 12.588(5) Å, c = 15.408(2) Å, beta = 101,90(2) degrees, V = 2282(1) Å(3), Z = 4, number of unique data [I >/= 2sigma(I)] = 2620, number of refined parameters = 311, R = 0.075. [Cu(2-BB)(NO(2))](ClO(4))(MeCN): triclinic, P&onemacr; (No. 2), a = 7.402(2) Å, b = 12.500(1) Å, c = 14.660(2) Å, alpha = 68.14(1) degrees, beta = 88.02(2) degrees, gamma = 78.61(1) degrees, V = 1233.0(4) Å(3), Z = 2, number of unique data [I>/= 2sigma(I)] = 2088, number of refined parameters = 319, R = 0.070. In all the complexes the 1-BB or 2-BB ligands coordinate the Cu(II) cations through their three donor atoms. The complexes with 2-BB appear to be more flexible than those with 1-BB. The nitrito ligand is bidentate in [Cu(2-BB)(NO(2))](ClO(4))(MeCN) and essentially monodentate in [Cu(1-BB)(DMSO-O)(NO(2))](ClO(4)). The copper(I) complexes exhibit nitrite reductase activity and react rapidly with NO(2)(-) in the presence of stoichiometric amounts of acid to give NO and the corresponding copper(II) complexes. Under the same conditions the reactions between the copper(I) complexes and NO(+) yield the same amount of NO, indicating that protonation and dehydration of bound nitrite are faster than its reduction. The NO evolved from the solution was detected and quantitated as the [Fe(EDTA)(NO)] complex. The order of reactivity of the Cu(I) complexes in the nitrite reduction process is [Cu(2-BB)](+) > [Cu(1-BB)](+) > [Cu(TB)](+) > [Cu(AcBB)](+).

Since the metabolic activity of the colonic flora plays a definite role in colon cancer and an increased incidence of this disease is reported after cholecystectomy, we studied the metabolic activity of the colonic flora in a group of postcholecystectomy patients and matched controls by measuring, as representative end products of the bacterial metabolism, their fecal bile acids (BA), fecal 3-methylindole (SK) and indole (IN), and respiratory methane and hydrogen. Patients had significantly higher SK and lower IN, and, among BA, higher lithocholic (LCA) and chenodeoxycholic acid concentrations and LCA/deoxycholic acid ratio in the stools than controls. Similar differences from controls were reported for colon cancer. Comparable bacterial metabolic activities are thus operative in the large bowel of postcholecystectomized and colon cancer patients. This supports the biological plausibility of the association of cholecystectomy and colon cancer.

Ultrasonography of the extremities was performed in 91 patients with unilateral or bilateral peripheral lymphedema of the arms or legs. Linear 3.5 to 10 mHz ultrasonographic linear probes were used in accordance with standardized procedure. The data demonstrated a volumetric increase of the lymphedematous limb with increased thickness of both the subcutaneous and subfascial (muscular) compartments consistent with fibrosclerosis in both compartments with chronic disease. Whereas dermal thickening was minimal, subcutaneous and subfascial changes were more prominent in primary than secondary lymphedema. By providing information about the volumetric and structural alterations with chronic lymphedema, ultrasonography safely and simply supplements conventional and isotopic lymphography in assessing patients with chronic lymphedema.