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Objective: Appendicectomy remains of the most common emergency operations in the United Kingdom. The exact etiologies of appendicitis remain unclear with only potential causes suggested in the literature. Social deprivation and ethnicity have both been demonstrated to influence outcomes following many operations. There are currently no studies evaluating their roles with regards to severity and outcomes following appendicectomy. Material and Methods: Demographic data were retrieved from health records for adult patients who underwent appendicectomy between 2010-2016 within a single NHS trust. To measure social deprivation, Indices of Multiple Deprivation (IMD) rankings were used. Histology reports were reviewed and diagnosis classified into predefined categories: non-inflamed appendix, uncomplicated appendicitis, complicated appendicitis and gangrenous appendicitis. Results: Three thousand four hundred and forty-four patients were identified. Mean age was 37.8 years (range 73 years). Using a generalized linear model, South Asian ethnicity specifically was found to be independently predictive of increased length of stay following appendicectomy (p< 0.001). Amongst South Asian patients, social deprivation was found to be further predictive of longer hospital stay (p= 0.005). Deprivation was found to be a predictor of complicated appendicitis but not of gangrenous appendicitis (p= 0.01). Male gender and age were also independent predictors of positive histology for appendicitis (p< 0.001 and p= 0.021 respectively). Conclusion: This study is the first to report an independent association between South Asian ethnicity and increased length of stay for patients undergoing appendicectomy in a single NHS trust. The associations reported in this study may be a result of differences in the pathophysiology of acute appendicitis or represent inequalities in healthcare provision across ethnic and socioeconomic groups. more...

Objective: Complex gallstone disease is associated with a higher risk of complication during laparoscopic cholecystectomy than biliary colic and simple cholecystitis. It is traditionally managed in a hepatopancreaticobiliary (HPB) unit where there is expertise for common bile duct exploration and repair. We developed a mentorship scheme for a busy upper gastro-intestinal (UGI) unit, with support from a specialist HPB unit to treat complex gallstone disease, to reduce the burden on the HPB unit and enable local treatment of patients. Material and Methods: Through the creation of a service level agreement, the specialist HPB unit were commissioned to provide mentorship for two surgeons at a large UGI unit with an interest in providing a complex gallstone service to their local population. Eight sessions of mentored operating were supported, with the provision for additional support if complications occurred. Results: There were 14 patients included in the mentorship phase of the programme from November 2015 to May 2017. Cholecystectomies were performed on patients with previously complex histories, which included: previous cholecystostomy; CBD stones and multiple ERCPs; suspected choledochoduodenal fistula; suspected cholecystoduodenal fistula; suspected Mirrizzi’s syndrome; previous significant intra-abdominal operation; and significant medical co-morbidities. There was one post-operative complication requiring a return to theatre, and one minor wound infection associated with the complex gallstone lists. Conclusion: We demonstrated a method to reduce the burden on specialist HPB unit for the operative management of complex gallstone disease and safely implement such a service at large UGI unit with an interest in providing a complex gallstone service. more...

Gallbladder torsion is a rare cause of acute abdominal pain and can be a diagnostic challenge for the general surgeon. We herein present a case of an 81-year-old man who presented with right-sided abdominal pain and signs of intra-abdominal infection. Transabdominal ultrasound, computed tomography (CT) and magnetic resonance cholangio-pancreatography (MRCP) scans could not identify with certainty the underlying cause of the symptoms and eventually the patient underwent a diagnostic laparoscopy, which revealed the presence of gallbladder torsion. Sequentially, a laparoscopic cholecystectomy was performed in a standard fashion and the patient had an uneventful post-operative recovery. Our case highlights the importance of diagnostic laparoscopy as a diagnostic and treatment tool in unclear cases of acute abdomen. J Curr Surg. 2020;10(3):28-31 doi: https://doi.org/10.14740/jcs405 more...

Η παρούσα Διδακτορική Διατριβή αποτελεί μια συστηματική προσπάθεια ανάπτυξης μεθόδου αποκατάστασης λίθινων μνημείων με τη χρήση μικροοργανισμών. Τις τελευταίες δύο δεκαετίες η έρευνα στο συγκεκριμένο τομέα έχει ενταθεί, τόσο για να βρεθούν τρόποι συντήρησης συμβατότεροι ως προς το υπόστρωμα, όσο και για να εξακριβωθεί ο ρόλος του βακτηριακού παράγοντα στη διάβρωση, αλλά και στην εκμετάλλευση της ικανότητάς του να λειτουργεί ως πυρήνας σχηματισμού ανθρακικού ασβεστίου. Η επιδιωκόμενη μέθοδος χρειάζεται να μην επηρεάζει σημαντικά το λίθο, να είναι εύκολη και άμεση στην εφαρμογή της, οικονομικά βιώσιμη και ανιχνεύσιμη μετά την ολοκλήρωσή της, ώστε να παρακολουθείται εύκολα η πορεία χρονικά μετά την επέμβαση.Οι μικροοργανισμοί απομονώθηκαν από τα αρχαία σημεία εξόρυξης Πεντελικού μαρμάρου και από το σπήλαιο της Παιανίας, έτσι ώστε να έχουν ήδη προσαρμοστεί στο ολιγότροφο περιβάλλον του λίθου. Από την Πεντέλη η δειγματοληψία πραγματοποιήθηκε χειμώνα μετά από έντονη βροχόπτωση, ώστε να μειωθούν οι μικροοργανισμοί οι οποίοι είχαν πρόσφατα επικαθίσει λόγω πιθανής μεταφοράς τους μέσω του αέρα. Την ίδια εποχή έγινε και η δειγματοληψία στο σπήλαιο της Παιανίας, όπου η ροή υδάτων από την επιφάνεια προς το εσωτερικό του σπηλαίου είχε ενεργοποιήσει τη μικροχλωρίδα. Η επιλογή έγινε για ετερότροφους μικροοργανισμούς οι οποίοι δεν έχουν απαιτητικές θρεπτικές αξιώσεις για την καλλιέργειά τους, ώστε να αρκούνται σε ένα γενικό θρεπτικό μέσο, μειώνοντας έτσι το εκτιμώμενο κόστος της διαδικασίας. Αναπτύχθηκε από την αρχή πλήρως η μεθοδολογία γενετικής ταυτοποίησης για στελέχη απομονωμένα από τα συγκεκριμένα υποστρώματα, διότι οι περισσότερες δημοσιεύσεις στον τομέα, δεν στόχευαν την αλληλούχηση σχεδόν ολόκληρου του 16S rDNA, αλλά ένα μικρό μέρος του. Επομένως, για μια ολοκληρωμένη προσέγγιση, κρίθηκε απαραίτητο να πραγματοποιηθεί ακριβέστερη ταυτοποίηση των μικροοργανισμών, προσέγγιση που να καθιστά την προτεινόμενη μέθοδο αποδεκτή από το σύνολο των ερευνητών. Ακολούθησε η δημιουργία του νέου θρεπτικού διαλύματος. Δοκιμάστηκαν μια σειρά εναλλακτικών συστατικών και επιλέχθηκε ο βέλτιστος συνδυασμός για τη πλειονότητα των απομονωμένων βακτηρίων και ειδικά για αυτά που παρουσίαζαν ταχύτερο σχηματισμό ανθρακικού ασβεστίου σε στερεές καλλιέργειες. Μετά την ταυτοποίηση των μικροοργανισμών και την εξέλιξη των θρεπτικών υγρών, έγινε έλεγχος της καμπύλης ανάπτυξης όλων των βακτηρίων σε υγρές καλλιέργειες, με σκοπό να εξακριβωθεί ο χρόνος στον οποίο το κάθε στέλεχος φτάνει στη μέγιστη πληθυσμιακή του κατάσταση. Ακολούθησαν οι πρώτες δοκιμές για απόθεση ανθρακικού ασβεστίου σε στερεές και υγρές καλλιέργειες, συγκεντρώνοντας σημαντικές πληροφορίες για την πολυμορφικότητα του βιο-υλικού και για το πότε ολοκληρώνεται η διαδικασία, λαμβάνοντας εξαρχής υπόψη ότι η βελτιστοποίηση αφορά και το χρόνο ολοκλήρωσης. Τρεις διαφορετικές συγκεντρώσεις θρεπτικού διαλύματος δοκιμάστηκαν αρχικά και αναλύθηκε διεξοδικά η μορφολογία, το είδος του ανθρακικού ασβεστίου, το χρώμα των κρυστάλλων, καθώς και οι μεταβολές του pH, της κατανάλωσης οξικού ανιόντος και της μείωσης του κατιόντος ασβεστίου σε συνάρτηση με το χρόνο. Με αυτόν τον τρόπο επελέγησαν οι μικροοργανισμοί με τις καλύτερες προϋποθέσεις.Η επιλογή του μαρμάρου ως υπόστρωμα έγινε για τους εξής λόγους: πρώτον αποτελεί ένα υλικό από το οποίο έχουν κατασκευαστεί μνημεία πολιτιστικής κληρονομιάς παγκόσμιου βεληνεκούς, ειδικά στον Ελλαδικό χώρο, δεύτερον δεν έχει δοκιμαστεί διεξοδικά βάσει της υπάρχουσας βιβλιογραφίας για την ικανότητα απόθεσης μικροοργανισμών πάνω σε αυτό και τρίτον θεωρούμε ότι σε σχέση με πιο πορώδεις λίθους αποτελεί τη δυσκολότερη επιφάνεια στην οποία μπορούν να αποθέσουν οι μικροοργανισμοί λόγω των ελάχιστων πόρων που διαθέτει. Οι πόροι μπορούν να προσφέρουν την κατάλληλη θέση ώστε τα βακτήρια να μπορέσουν να έρθουν σε επαφή με το υπόστρωμα, να το εποικήσουν και να αρχίσουν τη διαδικασία σχηματισμού ανθρακικού ασβεστίου. Αυτή τη «φιλοξενία» το Πεντελικό μάρμαρο δεν την προσφέρει. Αντιθέτως τα μόνα σημεία, όπως θα παρουσιαστεί στα αποτελέσματα, είναι τα σημεία θραύσης των κρυστάλλων ανθρακικού ασβεστίου και όπου αλλάζουν διεύθυνση, σχηματίζοντας εσοχές. Από τα προκαταρτικά πειράματα, επιλέχθηκαν τελικά οι δύο αποδοτικότεροι μικροοργανισμοί Cupriavidus metallidurans ACA-DC 4073 και Bacillus pumilus ACA-DC 4061, λαμβάνοντας υπόψη ποσοτικές παραμέτρους, όπως συνολική απόθεση πάνω στο δοκίμιο, βιωσιμότητα του στελέχους, αλλά και ποιοτικές παραμέτρους όπως να μη μεταφέρεται χρώμα από τον μικροοργανισμό στους κρυστάλλους. Με την εφαρμογή στατιστικού σχεδιασμού πειραμάτων βελτιστοποιήθηκε η απόθεση ως προς τρεις παράγοντες: συγκέντρωση θρεπτικού, συγκέντρωση εμβολιασμού κυττάρων και θερμοκρασία. Η διαδικασία έδωσε τη δυνατότητα με μια σειρά ταυτόχρονων πειραμάτων να παρακολουθηθεί υπό ποιες συνθήκες οι μικροοργανισμοί απέδωσαν τη μέγιστη απόθεση. Οι βέλτιστες συνθήκες που εντοπίστηκαν με το σχεδιασμό ελέγχθηκαν σε επιπλέον πείραμα για την εγκυρότητά τους και τα τελικά δείγματα αναλύθηκαν για την αντοχή του αποτεθέντος υλικού με την εφαρμογή υπερήχων. Τέλος, ως ολοκλήρωση της έρευνας, οι μικροοργανισμοί εφαρμόστηκαν σε μεγαλύτερη επιφάνεια μαρμάρου με ψεκασμό, σε μη αποστειρωμένες συνθήκες, ως προκαταρκτική προσομοίωση πραγματικής εφαρμογής των αποτελεσμάτων στο περιβάλλον. Το μόνο που διατηρήθηκε σταθερό ήταν η θερμοκρασία επώασης. Και τα δύο στελέχη απέδωσαν ικανοποιητικά σε υγρές καλλιέργειες υπό τις βέλτιστες συνθήκες αλλά και κατά τον ψεκασμό τους. Όπως θα παρουσιαστεί στα αποτελέσματα, η απόθεση είναι σημαντική στην επιφάνεια του μαρμάρου και παραμένει σχεδόν ανέπαφη με την εφαρμογή των υπερήχων. Σημαντική ανακάλυψη επίσης, αποτελεί η συστηματική απόθεση βατερίτη και όχι ασβεστίτη από το σύνολο των μικροοργανισμών, με τη χρήση του προτεινόμενου θρεπτικού. Ο βατερίτης λόγω της αστάθειάς του θεωρείται ότι μετατρέπεται σχετικά σύντομα σε ασβεστίτη. Η παρέμβαση των μικροοργανισμών στη διαδικασία σχηματισμού, απέδειξε ότι ο βατερίτης παραμένει σταθερός για παρατεταμένο χρονικό διάστημα χωρίς να ανιχνεύεται κάτι διαφορετικό, ακόμα και μετά την εφαρμογή υπερήχων. Είναι μια σημαντική διαφοροποίηση, η οποία βιβλιογραφικά ξεκίνησε να γίνεται αποδεκτή μόλις πρόσφατα. Παλαιότερα, η απόθεση βατερίτη θεωρείτο μειονέκτημα και οι μικροοργανισμοί οι οποίοι σχημάτιζαν αυτή τη δομή, δεν θεωρούνταν ικανοί να αποδώσουν σε διαδικασίες προστασίας μνημείων. Τα αποτελέσματα που παρουσιάζονται στη διατριβή αποδεικνύουν όμως το αντίθετο. Από τους δύο μικροοργανισμούς που τελικά χρησιμοποιήθηκαν, ο ένας (Cupriavidus metallidurans ACA-DC 4073) δεν έχει απομονωθεί στο παρελθόν από λίθινες επιφάνειες, όπως και ορισμένα από τα υπόλοιπα στελέχη που δοκιμάστηκαν. Επιπλέον ο Bacillus pumilus ACA-DC 4061 έχει αναφερθεί στη βιβλιογραφία, αλλά οι δυνατότητες απόθεσής του δεν είχαν αναλυθεί διεξοδικά. Βάσει των προϋποθέσεων που τέθηκαν στην πρώτη παράγραφο της περίληψης μπορούμε να θεωρήσουμε επιτυχή τα αποτελέσματα, εφόσον η επιδιωκόμενη μέθοδος:•Απαιτείται να μην επηρεάζει σημαντικά το λίθο: η διαδικασία απόθεσης διαφοροποίησε ελάχιστα τη μορφολογία της επιφάνειας ενώ η χρωματική μεταβολή για τα επιλεγμένα στελέχη μπορεί να ελεγχθεί βάσει του χρόνου εφαρμογής της μεθόδου.•Να είναι εύκολη και άμεση στην εφαρμογή της: η προτεινόμενη προσέγγιση χρειάζεται μερικές ημέρες για να είναι το επιλεγμένο στέλεχος έτοιμο προς ψεκασμό, ενώ η χρήση του ψεκασμού καθαυτού, προσφέρει άμεση κάλυψη μεγάλης επιφάνειας. Το θρεπτικό που χρησιμοποιείται μπορεί να παρασκευαστεί εύκολα και δεν χρειάζονται εξειδικευμένα συστατικά. •Να είναι οικονομικά βιώσιμη: το κόστος του μικροοργανισμού είναι μηδαμινό, μιας και απομονώθηκε από το περιβάλλον, ενώ του θρεπτικού είναι περιορισμένο, σε σχέση με τη χρήση κάποιου εξειδικευμένου θρεπτικού, που θα χρειαζόταν ακριβότερα συστατικά. Επιπλέον, ο χρόνος παραγωγής ικανών ποσοτήτων βακτηρίου έτοιμου προς εφαρμογή, δεν θεωρείται ικανός να αυξήσει σημαντικά το κόστος.•Να είναι ανιχνεύσιμη μετά την ολοκλήρωσή της: ο συστηματικός σχηματισμός βατερίτη προσφέρει αυτή τη δυνατότητα διότι η δομή του διαφοροποιείται από τη δομή του ανθρακικού ασβεστίου, αλλά και τυχόν προσμείξεων σε λίθινα υποστρώματα, τόσο του μαρμάρου, όσο και άλλων. Οι εικόνες λεπτών τομών αναδεικνύουν αυτήν τη δυνατότητα, καθώς η νέα απόθεση διαφοροποιείται σημαντικά και είναι ευκρινής στο οπτικό μικροσκόπιο. Επίσης, η ανάλυση με FT-IR, η οποία είναι αμεσότερη, δίνει τη δυνατότητα επιβεβαίωσης της διαφοροποίησης του βατερίτη από τον ασβεστίτη. more...

Background Obesity has a negative effect on quality of life (QoL). Bariatric surgery results in significant weight loss with improvement of QoL. Very few studies have evaluated QoL after sleeve gastrectomy (SG), especially with a long-term follow-up. Objectives To assess long-term longitudinal changes of QoL of a laparoscopic SG cohort, with the obesity specific Moorehead-Ardelt II questionnaire (MAII) and to identify parameters associated with QoL outcome. Setting Bariatric Unit, University Hospital of Heraklion, Greece. Methods Morbidly obese patients admitted for laparoscopic SG over a 30-month period were prospectively studied. QoL was assessed using the Greek version of the MAII questionnaire and a visual analog scale preoperatively and at 6, 12, 24, and 60 months postoperatively. Anthropometric data and obesity-related co-morbidities were recorded. Results A total of 95 patients with mean age of 37.4 ± 9.2 years and body mass index of 48.3 ± 7.1 kg/m2 completed the 5-year follow-up. Percentage excess body mass index loss was 51.7 ± 14.2, 64.8 ± 16.9, 67.4 ± 17.7, and 55.8 ± 25.5 at 6, 12, 24, and 60 months, respectively. All obesity-related co-morbidities improved significantly. MAII score increased from −.38 ± 1.3 preoperatively to 1.77 ± .8, 2.08 ± 0.8, 2.12 ± .7, and 1.67 ± 1.1 at the above time points, respectively (trend P Conclusions Laparoscopic SG is an effective bariatric operation, resulting in significant weight loss and improvements in QoL. Female sex and higher MAII score at 6 and 24 months predict better long-term QoL outcome. more...

Obesity has been identified as an independent risk factor for a wide range of health conditions. Therefore, there is a clear need for high quality Bariatric research in order to improve patient selection, outcomes and safety for patients with obesity. We sought to identify and compare the quantitative and qualitative publication output from Bariatric centres in England. We identified 42 National Health Service (NHS) Trusts and 162 surgeons providing Bariatric services in England. A median of 4 (range 1-7) Bariatric surgeons were identified per centre. Eight NHS Trusts (19%) and 75 surgeons (46.3%) had no Bariatric publications during the study period, while 87 surgeons published a total of 432 Bariatric papers. Only 15 surgeons (9%) had ≥10 publications within the study period. However, these surgeons produced >50% of all Bariatric publications. Departments with more than 4 surgeons produced a significantly higher number of Bariatric publications (median 8.5 vs 2, p = 0.01). There is significant variation in research contribution amongst Bariatric centres in England. Academia should be encouraged and promoted across all bariatric services in order to broaden our understanding on Bariatric outcomes by expanding the service and proportional increase in funding. Given that a number of health conditions can afflict individuals living with obesity, bariatric surgery research becomes all the more important. more...

Laparoscopic adjustable gastric band (LAGB)-related complications have been reported in significant numbers of patients often leading to band removal. Increasingly revisional bariatric surgery (RBS) is offered, most commonly either band to Roux-en-Y gastric bypass (B-RYGB) or band to sleeve gastrectomy (B-SG). We conducted a systematic review and meta-analysis of studies to evaluate the efficacy of RBS following failed LAGB. Medline, Embase, The Cochrane Library and NHS Evidence were searched for English language studies assessing patients who had undergone LAGB and who subsequently underwent either B-RYGB or B-SG. Thirty-six studies met the inclusion criteria. There were 2617 patients. B-RYGB was performed in 60.5% (n = 1583). There was one death within 30 days (0.0004%). The overall pooled morbidity rate was 13.2%. There was no difference between the B-RYGB and B-SG groups in morbidity, leak rate or return to theatre. Percentage excess weight loss (%EWL) following the revisional procedure for all patients combined at 6, 12 and 24 months was 44.5, 55.7 and 59.7%, respectively. There was no statistical difference in %EWL between B-RYGB and B-SG at any time point. The rates of remission of diabetes, hypertension and obstructive sleep apnoea were 46.5, 35.9 and 80.8%, respectively. Randomised controlled trials (RCTs) do not exist on this issue but the available observational evidence does suggest that RBS is associated with generally good outcomes similar to those experienced after primary surgery. Further, high-quality research, particularly RCTs, is required to assess long-term weight loss, comorbidity and quality of life outcomes. more...

Background: Diabetes mellitus is the most common cause of end-stage renal disease, which is associated with increased morbidity and mortality. The impact of bariatric surgery on chronic kidney disease is unclear. Objectives: Our primary aim was to assess the impact of bariatric surgery on estimated glomerular filtration rate (eGFR) in type 2 diabetes (T2D) patients. Our secondary aim was to compare the impact of bariatric surgery versus routine care on eGFR in patients with T2D. Setting: University Hospital, United Kingdom. Methods: A retrospective cohort analysis of adults with T2D who underwent bariatric surgery at a single center between January 2005 and December 2012. Data regarding eGFR were obtained from electronic patients records. eGFR was calculated using the Modification of Diet in Renal Disease formula. Data regarding patients with T2D who did not undergo bariatric surgery ("routine care") were obtained from patients attending the diabetes clinic at the same center from 2009 to 2011. Results: One hundred sixty-three patients were included (mean age 48.5±8.8 yr; baseline body mass index 50.8±9.1 kg/m2) and were followed for 3.0±2.3 years. Bariatric surgery resulted in an improvement in eGFR (median [interquartile range] 86.0 [73.0-100.0] versus 92.0 [77.0-101.0] mL/min/1.73 m2 for baseline versus follow-up, respectively; P = .003), particularly in patients with baseline eGFR≤60 mL/min/1.73 m2 (48.0 [42.0-57.0] versus 61.0 [55.0-63.0] mL/min/1.73 m2; P = .004). After adjusting for baseline eGFR, glycated hemoglobin (HbA1C), body mass index, age, and gender, bariatric surgery was associated with higher study-end eGFR compared with routine care (B = 7.787; P< .001). Conclusion: Bariatric surgery results in significant improvements in eGFR in T2D patients, particularly those with an eGFR≤60 mL/min/1.73 m2, while routine care was associated with a decline in eGFR. more...

Introduction Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks. Methods A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded. Results 924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1). Conclusion Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time., Highlights • Methylene blue leak testing in bariatric surgery is not evidence based. • Of 924 patients undergoing bariatric surgery, only two leak tests were positive. • There is no correlation between leak test positivity and postoperative leak. • Methylene blue leak testing is safe, with no adverse events in our cohort. more...

Mechanical gastro-intestinal anastomosis using stapler is a critical step in laparoscopic Roux-en-Y gastric bypass (RYGB). To date the effect of the direction of staples on anastomotic leak has not been investigated. The study aim was to investigate the impact of the direction of staples on the integrity of the gastro-jejunal anastomosis. Eight gastro-jejunostomy (GJ) models were performed using porcine stomach and small intestine. Specimens were divided into group A where the cartridge was in the gastric lumen with the anvil in the jejunal lumen and vice versa in group B. Enterotomy was closed and gastric and jejunal ends were stapled off. Burst pressure (BP) was measured by infusion of methylene blue saline into the GJ model until leak occurred. Site of leak, BP, and total volume (TV) infused were recorded. Compliance (C) was calculated from the equation ΔTV/ΔBP. The BP was greater in group A compared to group B (18 mmHg (range 15–25) versus 11 mmHg (range 8–15); p = 0.045) despite similar TV between the groups 60.00 mL (range 55.00–65.00) versus 51.25 mL (range 40.00–60.00); p = 0.11). The compliance did not significantly differ between groups A and B (6.38 mL/mmHg (range 4.34–8.59) versus 5.61 mL/mmHg (range 3.93–7.21); p = 0.48). BP recorded when the stapler cartridge was introduced in the gastric lumen was higher than when it was introduced from the jejunal lumen. The lack of difference in compliance between groups suggests that the difference in BP was due to the difference in the direction of staples. more...

Introduction Laparoscopic Heller’s myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. Methods We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. Results Sixty patients with a mean age of 41±13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0–2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (pConclusions LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year. more...

BACKGROUND Laparoscopic anti-reflux surgery has become the standard treatment for symptomatic gastro-oesophageal reflux disease refractory to medical therapy. Successful anti-reflux surgery involves safe, minimally invasive surgery, resulting in symptom resolution with minimal side effects. This study aims to assess the feasibility and safety of day case anti-reflux surgery focussing on peri- and post-operative outcomes as a measure of success. METHODS Data was collected from the hospital database from 2003 to 2012. Data collection included demographics, surgeon, mode of admission, length of stay and complications. Electronic records were independently scrutinised for all patients with a length of stay of more than two nights. RESULTS 723 patients underwent laparoscopic fundoplication ± small hiatus hernia repair ( more...

The aim of this study was to evaluate the effects of surgically induced weight loss on the abdominal adipose tissue depots and the metabolic profile in morbidly obese (MO) patients.The study was performed with a semi-automated quantification of adipose tissue compartments on single-slice abdominal CT series before surgery, 6 and 12 months after bariatric surgery. Thirty-eight MO patients with mean age of 35.7 ± 10.1 years and mean body mass index (BMI) of 43.6 ± 6.5 kg/m(2) were studied (20 patients underwent gastric banding and 18 patients underwent sleeve gastrectomy). Anthropometric measurements, metabolic and inflammatory parameters were analyzed in each patient.Markedly decreased levels of total abdominal adipose tissue, abdominal subcutaneous adipose tissue (AbSAT) and visceral adipose tissue (VAT) at 6 and 12 months were noted in comparison to the preoperative values. The total % reduction of VAT was significant higher in comparison to the total % reduction of AbSAT at 12 months after bariatric surgery (P0.01) with the mean ratio of AbSAT/VAT to increase from 4.1 ± 1.7 preoperatively to 6.2 ± 3.1 at 12 months postoperatively (P0.001). In addition, high-sensitivity C-reactive protein (hsCRP) decreased significantly with weight loss after bariatric surgery and the total abdominal lipid loss was related to the decrease in hsCRP.Significant changes in abdominal lipid deposition occurred in MO patients 6 and 12 months after bariatric surgery. The changes were significantly, correlated with the magnitude of BMI loss. The fat redistribution may contribute to the improvements in metabolic abnormalities. more...

OBJECTIVE: To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on fasting and meal-stimulated release of the gut hormones ghrelin, pancreatic polypeptide (PP), peptide-YY (PYY), glucagon-like peptide-1 (GLP-1), and amylin and of the adipocytokine leptin. BACKGROUND: Mounting evidence suggests that the mechanisms of weight loss and the improvement in glucose metabolism seen after LSG are related not only to gastric restriction but also to neurohormonal changes. METHODS: : Fasting and postprandial levels at 60 and 120 minutes after a standard test meal of the above peptides and glucose metabolism indices were evaluated in 15 consecutive morbidly obese (MO) subjects before and 6 and 12 months after LSG. As study controls, 15 lean subjects matched for age and sex were also assessed. RESULTS: Body mass index values notably decreased at 6 and 12 months (P < 0.01), postoperatively. In addition, an overall improvement of the glycemic profile of MO patients was noted. After LSG, markedly decreased fasting and postprandial levels of ghrelin, amylin, and leptin were observed. A significant postprandial increase of PYY and GLP-1 levels was also noted postoperatively. Interestingly, significantly increased levels of PP were noted only at 60 minutes postprandially after LSG. CONCLUSIONS: LSG markedly improved glucose homeostasis and generated significant changes in ghrelin, PP, PYY, GLP-1, amylin, and leptin levels. These multiple hormonal actions may have several beneficial effects on the underlying mechanism of weight loss, demonstrating that LSG could be more than just a restrictive bariatric operation. more...

The aim of the present study was to evaluate the effects of surgically induced weight loss on the metabolic profile and adipocytokine levels in premenopausal morbidly obese females.Twenty premenopausal morbidly obese (MO) women with a median age of 34 years (range: 24-48 years) and a median body mass index (BMI) of 41.47 kg/m(2) (range: 38.0-56.73 kg/m(2)) were studied (13 women underwent gastric banding and 7 women underwent sleeve gastrectomy). In addition, 20 lean premenopausal women with a median age of 32 years (range: 22-44 years) and a median BMI of 20.0 kg/m(2) (range: 18.5-24.7 kg/m(2)) were also studied. Anthropometric measurements and metabolic parameters were analyzed in each patient, along with changes in leptin, adiponectin, resistin, and interleukin-6 (IL-6) before surgery, 6 months after surgery, and 12 months after surgery. Comparisons with the reference normal-weight subjects were also performed.Both weight and BMI were found to be significantly decreased postoperatively. A 54.5% loss of excess BMI was observed 12 months after surgery, and was associated with significant improvement in all anthropometric and metabolic parameters. Twelve months after surgery we also observed decreased levels of serum leptin, resistin, and IL-6; increased levels of serum adiponectin; and a remarkable improvement in metabolic syndrome markers. Furthermore, postoperative serum resistin and IL-6 levels were found to reach those of normal-weight volunteers.The results of this study suggest that weight loss through restrictive bariatric surgery results in a significant reduction in leptin, resistin, and IL-6 levels, and an increase in adiponectin levels, in addition to improving insulin sensitivity and glucose and lipid homeostasis in young morbidly obese female patients. These changes were significantly correlated with the magnitude of weight loss. more...

Aims The aim of this study was to evaluate the effect of surgery on the kinetics of CTCs in breast cancer patients. Methods The detection of CK-19 mRNA-positive CTCs in the blood by RT-PCR was analysed in 104 stage 0-IIIA patients at 4 time-points: prior to surgery, upon completion, 24 h after surgery and 15 days after surgery. Furthermore, a late sample was assessed prior to initiation of adjuvant chemotherapy in a subgroup of 53 patients. As negative controls, peripheral blood was obtained from 50 female patients undergoing excision of benign breast lesions and from 11 female patients receiving surgery for early-stage colorectal cancer. Results A significant percentage of blood samples from breast cancer patients (14.4%) were negative for CK-19 preoperatively but turned transiently positive early postoperatively. However, no significant difference in CK-19 mRNA detection was noted among the first 4 examined time-points. There was no significant correlation between CK-19 mRNA-positive cells and classic prognostic factors. A significant increase in CK-19 mRNA-positivity (32.1%) was observed in a late sample of the subgroup of 53 patients before adjuvant chemotherapy after a median of 54 days, postoperatively. Conclusions Surgery may result in CTC detection in a small proportion of early breast cancer patients. There is no clear correlation to indicate which patients are expected to have detectable CTCs. Although CTCs are detected in a small proportion of patients during the perioperative period, the detection rate may increase over time and with longer follow-up. more...

Cobalt is an abundant metal ion present in the abiotic and biological world. The chemical reactivity of Co(II) is exemplified through complex interactions with variable molecular mass ligands, including amino acids, peptides, variable nature organic ligands, and/or phospho(nate)-derivatives thereof. Poised to gain insight into the chemical reactivity of Co(II) toward the family of mixed (carboxy)phosphonate-containing ligands, pH-specific aqueous reactions were carried out between Co(II) and N,N-bis(phosphonomethyl)-glycine (NTA2P), leading to a new pH-structural variant species (NH4)3[Co(C4H6O8NP2)(H2O)2]·4H2O (1) at pH 8. Compound 1 was characterized analytically, spectroscopically (FT-IR, UV–Vis, EPR), and magnetically. X-ray crystallography reveals a mononuclear complex of Co(II) in an NO5 octahedral environment. The solid state magnetic and EPR data on 1 suggest the presence of a high-spin Co(II) in a distorted octahedral geometry, with a ground state of an effective spin S = 1/2. The solution UV–Vis and EPR data suggest retention of the integrity of 1, consistent with the magnetization measurements. Detailed aqueous speciation studies on binary Co(II)–carboxylate (NTA) and all Co(II)–(carboxy)phosphonate (NTAxP; x = 1–3) systems reveal the aqueous distributions of all species involved in the respective systems and project a mononuclear species not unlike that of 1 in the Co(II)–NTA2P system. The structural and chemical attributes of the title complex reflect the (a) pH-dependent chemical reactivity in the binary Co(II)–NTA2P system, and (b) structure–activity correlations in the aqueous media linking both high and low pH-structural variants. To this end, fundamental structural properties influence the reactivity of Co(II) toward phosphonate and mixed carboxyphosphonate ligands and are ultimately exemplified as a function of phosphonate-containing moieties in NTA derivatives. The variably configured species in such binary Co(II)–ligand systems define the pH dependence and nature of interactions between the two reagents, and could serve further as precursors in the design and discovery of new Co(II)–organophosphonate materials of specific structural lattice, spectroscopic, and magnetic properties. more...

Sleeve gastrectomy is gaining popularity whether as a primary, staged or revisional operation. The aim of this study is to evaluate the perioperative safety and the learning curve for laparoscopic sleeve gastrectomy (LSG). We performed a retrospective review of the prospectively collected data for all patients who underwent LSG for the treatment of morbid obesity at our institution from January 2003 to December 2008. Data from 230 consecutive patients [male 47%, female 53%; mean age 44.0 ± 10.0 years, mean preoperative body mass index (BMI) 56.7 ± 11.5 kg/m2], who were operated upon by three surgeons with different degrees of bariatric experience, were analyzed. There was no 30-day mortality, but there were two cases of late mortality (0.87%). Early complications were noted in 23 cases (10.0%), including 10 cases of leak (4.3%) and 10 cases of hemorrhage (4.3%). In 17 cases (7.4%) reoperations were performed. The rates of overall and major complications did not differ among surgeons or between early and late period of experience for the three surgeons; this trend held true individually and in subgroups. Overall, over the course of the learning curve, a significant decrease in operative time was noted. The only factor that was independently associated with complications was use of buttress material; the likelihood of complications was found to be 72% lower in patients in whom buttress material was used. LSG constitutes a potentially safe anti-obesity procedure with acceptable morbidity. Experience at the beginning can be discouraging, even for surgeons with advanced laparoscopic skills. LSG can be performed safely, with proper mentoring and in appropriate settings, even by less experienced bariatric surgeons. The use of staple-line reinforcement was associated with improved perioperative outcomes, and it should be considered in an attempt to decrease leaks. more...

Bardet-Biedl syndrome (BBS) is a rare genetic disorder characterized by a wide range of phenotypic variability and associated with the development of life-threatening obesity. Birth weight tends to be normal, but rapid weight gain begins after the first year, probably due to polyphagia rather than abnormalities in energy metabolism. A morbidly obese 16-year-old male patient with BBS was referred to our institution, after nonsurgical methods of weight control had failed, for surgical treatment of his obesity. His preoperative body mass index (BMI) was 52.28 kg/m(2) (height, 1.84 m; weight, 177 kg) and was above the 99th centile for age and gender. The patient underwent laparoscopic Roux-en-Y gastric bypass (RYGBP). The postoperative period was uneventful. Three and a half years after the operation, the patient's weight has decreased to 118 kg (BMI, 34.85 kg/m(2)), while significant improvement in his hypertension, hyperuricemia, and mobility has been noted. In our BBS patient, RYGBP proved to be safe and effective; nevertheless, longer follow-up is required to evaluate the weight loss durability and to assess the lasting beneficial effect of surgical intervention on genetically determined co-morbidities. more...

Parathyroid carcinoma constitutes a rare cause of hyperparathyroidism. Five patients, presenting with symptoms and clinical signs of parathyroid hyperfunction, were diagnosed with parathyroid carcinoma in our department over a 12-year period. The experience we gained in the management of these tumors is presented. The aim of this study is to elucidate the clinical features of the disease, the surgical treatment, and the sensitivity of the imaging modalities used to enhance the diagnostic ability. Preoperative recognition and intraoperative identification of this rare endocrine malignancy require a high index of clinical suspicion. Intraoperative awareness is needed of the malignant potential of the encountered lesion. more...

The implantation of an intragastric balloon constitutes a short-term effective non-surgical intervention to lose weight. The aim of this study was to evaluate retrospectively the clinical outcome and safety of gastric balloon therapy (GBT) in extremely obese patients.One hundred and nine super- and super-super-obese patients, 64 males and 45 females, mean age 39.1+/-8.4 years, mean body mass index (BMI) 68.8+/-8.9 kg/m2, who underwent GBT for weight loss, were studied retrospectively. GBT was assessed in massively obese patients concerning tolerance, weight loss, number of comorbidities and complications.A significant reduction in patients' weight and BMI was evident after GBT. Regarding safety, no major complications occurred. Minor complications at balloon placement and removal occurred in one (0.9%) and three patients (2.8%) respectively. Mean duration of GBT was 177.6+/-56.8 days. After GBT, the mean weight loss was 26.3+/-15.2 kg (p0.001) and the mean BMI reduction was 8.7+/-5.1 kg/m2 (p0.001) representing a mean percentage of excess BMI lost (%EBL) of 19.7+/-10.2. The highest BMI loss was observed in patients with BMI80 kg/m2. A noteworthy improvement of comorbidities in 56.8% of the patients was also noted. Of the 109 patients, 69 received subsequent bariatric surgery. All the procedures were performed laparoscopically. Ten patients, with a mean BMI of 68.6+/-10.6 kg/m2 after the removal of the first BIB, received a second BIB resulting in a non-significant weight and BMI loss of 6.3+/-9.4 kg and 1.8+/-2.9 kg/m2, respectively.Our study indicates the safety and efficacy of GBT in extremely obese patients particularly as a first step before a definitive anti-obesity operation. GBT appears to be a safe, tolerable, and potentially effective procedure for the initial treatment of morbid obesity. more...

BACKGROUND: Gastric balloon therapy (GBT)is a temporay, nonsurgical treatment for obesity. This retrospective study evaluates safety and efficacy of GBT in obese patients. METHODS: The BioEnterics® Intragastric Balloon (BIB) was endoscopically implanted into each patient's stomach and inflated with saline (450–750 ml). Extraction was planned after 6 months. Data from 190 patients receiving GBT were evaluated. Mean weight was 168.4 − 58.9 kg (range 76.5–310.0) and mean BMI was 55.6 − 17.5 kg/m(2) (range 27.0–95.7). RESULTS: Mean weight loss at the time of balloon removal was 21.2 − 14.0 kg (range 0–80.0). The mean BMI loss and EBL (Excess BMI Loss) were 7.2 − 4.9 kg/m(2) (range 0–28.9) and 30.1 − 26.4% (0–184.4), respectively. The most substantial weight and BMI loss was observed in the most massively obese patients. Minor complications at implantation were encountered in 2 cases (1.1%) due to leakage of the balloon, and in 3 cases at explantation (1.6%). No mortality or major complications such as gastric perforation or ulcers occurred. Of the 190 patients, 76 received subsequent surgery (40.0%). Of those, 7 patients had a BMI < 50 kg/m(2) while all other patients where super-obese(BMI > 50 kg/m(2)). 58 patients (30.5%) with a BMI > 60 kg/m(2) which had an extra ordinary high operation risk were able to receive subsequent surgical treatment because of a substantial weight loss and/or reduced comorbidity. CONCLUSION: GBT appears to be a safe, tolerable, and potentially effective procedure for the initial treatment of morbid obesity. more...

Efforts to delineate the interactions of Al(III), a known metallotoxin, with low molecular mass physiological substrates involved in cellular processes led to the investigation of the structural speciation of the binary Al(III)–quinic acid system. Reaction of Al(NO3)3 · 9H2O with d -(−)-quinic acid at a specific pH (4.0) afforded a colorless crystalline material K[Al(C7H11O6)3] · (OH) · 4H2O (1). Complex 1 was characterized by elemental analysis, FT-IR, DSC–TGA, 13C-MAS NMR, solution 1H and 13C NMR, and X-ray crystallography. The structure of 1 reveals a mononuclear octahedral complex of Al(III) with three singly ionized quinate ligands bound to it. The three ligand alcoholic side chains do not participate in metal binding and dangle away from the complex. The concurrent study of the aqueous speciation of the binary Al(III)–quinic acid system projects a number of species complementing the synthetic studies on the binary system Al(III)–quinic acid. The structural and spectroscopic data of 1 in the solid state and in solution emphasize its physicochemical properties emanating from the projections of the aqueous structural speciation scheme of the Al(III)–quinic acid system. The employed pH-specific synthetic work (a) exemplifies essential structural and chemical attributes of soluble aqueous species, arising from biologically relevant interactions of Al(III) with natural α-hydroxycarboxylate substrates, and (b) provides a potential linkage to the chemical reactivity of Al(III) toward O-containing molecular targets influencing physiological processes and/or toxicity events. more...

Sleeve gastrectomy (SG), which, thus far, is showing good resolution of comorbidities and good weight loss, shows increasing popularity among bariatric surgeons. The aim of this study was to evaluate clinical outcome and the gastric emptying of solid foods, 24 months after SG.Fourteen morbidly obese patients, four males and ten females, median age 41 years (range 29-65), median body mass index (BMI) 49.46 kg/m(2) (range 41.14-55.63), who underwent SG for weight loss, were studied prospectively. Nine patients underwent gastric emptying studies, using radioisotopic technique before, 6 months and 24 months after the operation. The remaining five patients underwent gastric emptying studies, 6 months and 24 months after the operation.A significant reduction in patients' weight and BMI was evident at 6, 12 and 24 months postoperatively. In the nine patients who underwent gastric emptying studies pre-, 6 and 24 months postoperatively, the T-lag phase duration significantly decreased, following the SG, from 17.30 (range 15.50-20.90) min, to 12.50 (range 9.20-18.00) min at 6 months and 12.16 (range 10.90-20.00) min at 24 months postoperatively (P0.05). The gastric emptying half time (T1/2) accelerated significantly postoperatively from 86.50 (range 77.50-104.60) min, to 62.50 (range 46.30-80.00) min at 6 months and 60.80 (range 54.80-100.00) min at 24 months after SG (P0.05). The percentage of gastric emptying (%GE) increased significantly postoperatively, from 52 (range 43-58) % to 72 (range 57-97) % at 6 months and 74 (range 45-82) % at 24 months, following SG (P0.05). No differences in gastric emptying were observed, when values at 24 months were compared to those at 6 months postoperatively. When the whole group of 14 patients was studied, there were also no significant changes in T-lag, T1/2 and %GE between 6 and 24 months postoperatively.Our study indicates the constant effect of SG in the acceleration of gastric emptying of solids, which occurs faster, not only in short but also in long-term postoperatively. Such effects on gastric motility, in combination with the reported alterations in gut hormones, may explain how this 'food limiting' operation results in weight loss. more...

Intraperitoneal chemotherapy has been recommended as a treatment option for ovarian cancer with peritoneal dissemination. Although its treatment duration is significantly shorter, intraoperative hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) has several advantages over simple intraperitoneal instillation chemotherapy. While platinum compounds have usually been used, only a few have administered paclitaxel during HIPEC. Its large molecular weight suggests a much more favorable pharmacokinetic profile than that of platinum compounds. The pharmacokinetics of paclitaxel during and after HIPEC have not been studied before.Thirteen women, mainly with ovarian cancer, underwent cytoreductive surgery and HIPEC with 175 mg/m(2) paclitaxel for 2 h. Morbidity was noted. Peritoneal fluid samples and blood samples were harvested during and until 5 days after HIPEC for pharmacokinetic study in ten patients.No treatment-related mortality was noted. Overall morbidity was 38% (two wound infections, one deep venous thrombosis, two grade 1 thrombopenia, one grade 2 neutropenia, and one grade 3 pancytopenia). Mean maximal intraperitoneal paclitaxel concentration was 101 mg/L, which was an average of 1178 times higher than the peak plasma levels. The peritoneal fluid versus plasma AUC ratio was 1462 for the 2-h HIPEC duration and 366 for the total 5-day study period. Cytotoxic drug concentrations were detected in peritoneal fluid for a mean period of 2.7 days, despite drainage of the drug solution after 2 h of treatment.HIPEC with paclitaxel following cytoreductive surgery is feasible, relatively safe, and associated with a highly favorable pharmacokinetic profile, despite its short treatment duration. Larger studies with a more homogenous patient cohort and adequate follow-up should be performed to demonstrate its efficacy. more...

Diet and surgically-induced weight loss have been shown to lead to alterations in motor and sensory function of the stomach.We investigated the clinical outcome and gastric emptying of solid foods in morbidly obese (MO) patients following sleeve gastrectomy (SG). We studied 23 MO patients [(7 males, 16 females), mean age 38.9 ±11.0 years (range 20–64 years), mean weight 135.1 ±19.0 kg (range 97–167 kg), mean BMI 47.2 ±4.8 kg/m2 (range 39.6–56.0 kg/m2)] who each underwent a sleeve gastrectomy (SG) for weight reduction. At the monthly follow-up visits, variations in weight and BMI changes, postoperative meal size and frequency, and presence of gastrointestinal symptoms were recorded. 11 patients underwent scintigraphic measurement of the gastric emptying of a solid meal pre- and 6 months postoperatively. A significant reduction in patients’ weight was evidenced at 6 and 12 months postoperatively [98.6 ±11.8 kg and 87.0 ±10.7 kg respectively (P=0.001)]. BMI decreased to 35.2 ±4.3 kg/m2 at 6 months and to 31.1 ±4.5 kg/m2 at 12 months, respectively (P=0.001). Although meal size was drastically reduced, meal frequency increased postoperatively in 12 patients (52.2%). Only 5 patients (21.8%) reported occasional vomiting after meals following SG. The gastric emptying half-time (T1/2) accelerated (47.6 ±23.2 vs. 94.3 ±15.4, P more...

Rhabdomyolysis is a rare complication of serious surgical procedures, and constitutes a clinical and biochemical syndrome, caused by injury and destruction of skeletal muscles. It is accompanied by pain in the region of the referred muscle group, increase in creatine phosphokinase levels, myoglobinuria, often with severe renal failure, and finally multi-organ system failure and death, if not treated in time. The main risk factor in the development of postoperative rhabdomyolysis is prolonged intraoperative immobilization of the patient. Morbidly obese patients who undergo laparoscopic bariatric operations should be considered high-risk for rhabdomyolysis, from extended immobilization and pressure phenomena in the lumbar region and gluteal muscles. We report a 20-year-old woman with BMI 51, who underwent a prolonged laparoscopic Roux-en-Y gastric bypass. Postoperatively, she presented severe myalgia in the gluteal muscles and lumbar region, oliguria and creatine phosphokinase levels that reached 38,700 U/L. She was treated with intensive hydration and analgesics, and did not develop acute renal failure because diagnosis and treatment were attained immediately. more...

Background Guidelines for the learning period of sentinel lymph node biopsy in breast cancer do not address important details such as the false negative rate way of calculation and the number of patients with positive axilla that should be included among the cases of this period. The aim of this study was to identify refinement points which should be included in the guidelines. Methods We studied 138 breast cancer cases of the sentinel lymph node biopsy learning period of three surgeons. The sentinel node was identified using isosulfan blue or technetium sulfur colloid or both. All patients underwent complementary axillary dissection. Results All three surgeons (A, B, C) fulfilled the guidelines' false negative rate criteria of 5, 0 and 5%, respectively, after 20 cases. However, only six, 10 and 10 cases with positive axilla, respectively, were included and the false negative rates using only these cases were 17, 0 and 10%, respectively. Conclusions Current guidelines may lead surgeons to inappropriate conclusions about their ability to perform sentinel lymph node biopsy with an acceptable false negative rate. The learning period should include as many cases with positive axilla as possible and the false negative rate should be calculated only on those patients. more...

Hintergrund: Der temporAre Einsatz eines Magenballons zur Behandlung der Adipositas Grad1 und 2 nimmt weltweit zu; bei der Adipositas Grad 3 wird der Magenballon als adjuvantes Hilfsmittel zur prAoperativen Gewichtsreduktion implantiert. Ziel dieser retrospektiven Kohorten analyse ist, die Wirksamkeit des Magenballons auf Gewichtsreduzierung und das Risikoprofil der Methode zu evaluieren. Methoden: Retrospektive Kohortenanalysen aus 4 Adipositas-Zentren, in denen der Magenballon seit 2001 regelmAsig implantiert wurde. Ergebnisse: Von Februar2001 bis April 2008 wurde bei 634 Patienten ein Magenballon implantiert (BIBTM Intragastric Balloon System; Allergan Medical, Irvine, CA, USA). Die Geschlechterverteilung war 31,5% MAnnerzu 68,5% Frauen; das Durchschnittsalter betrug 41,5 Jahre. Das durchschnittliche Ausgangsgewicht lag bei 126 kg. Der initiale BMI bei Implantation des Magenballons war 42,5 kg/m2. Die Implantation der Prothese war in allen FAllen unkompliziert. Der durchschnittliche Gewichtsverlust lag bei 20,75 kg bzw. 7,05 BMI-Punkten. more...

Fatty acid composition of adipose tissue is a most reliable biomarker of long-term dietary fatty acid intake. Few studies have implemented biomarkers of fatty acid intake in relation to breast cancer. In this study the relation between adipose tissue composition and breast cancer was investigated.Fatty acid composition in breast and buttock adipose tissue from 94 Greek women with breast cancer and 57 with benign breast tumors was determined. Multivariate analysis was performed to determine the association between fatty acid groups and breast cancer risk.In pre-menopausal women, elevated total polyunsaturated fatty acids (PUFA) in breast adipose tissue and N-3 PUFA in buttock adipose tissue were associated with reduced odds of breast cancer (odds ratio, OR=0.19; 95% confidence interval, CI=0.05-0.76, p0.02 and OR=0.02; 95% CI=0.0009-0.36, p0.009).Adipose total PUFA and N-3 PUFA were inversely-related to breast cancer risk in Greek pre-menopausal women. These results may have specific impact on habitual fat intake recommendations. more...

Morbid obesity adversely affects quality of life. The assessment of health-related quality of life (HRQoL) needs specific measuring instruments. The Moorehead–Ardelt Quality-of-Life Questionnaire II (MA II) is an obesity-specific instrument widely used in bariatric surgery. The objective of this study was to translate and validate the MA II in Greek language. The study included the translation of the MA II followed by cross-validation with the Greek version of 36-item Short Form Health Survey (SF-36) and a Visual Analogue Scale (VAS) in subjects visiting an obesity clinic. Internal consistency was indicated by Cronbach’s alpha coefficient and test–retest reliability by intraclass correlation coefficient (ICC). Construct validity was studied using Pearson’s correlations between the MA II, the SF-36 and the VAS. A total of 175 patients were enrolled in the study. Test–retest analysis was applied to 40 patients with a 15-day interval. A very good internal consistency with Cronbach’s alpha coefficient of 0.85 was shown. Excellent test–retest reliability was observed with an overall ICC of 0.981. Significant correlations between the Greek MA II and the other instruments as well as of each item of the MA II with the scores of SF-36 and the VAS indicated high construct and convergent validity. A negative correlation between the translated MA II total score and BMI confirmed high clinical validity. The Greek version of the MA II questionnaire has been generated and shown to be valid and reliable in measuring HRQoL in morbidly obese patients before and after bariatric surgery. more...

BACKGROUND: Ulcers at the gastrojejunostomy site are a common problem after gastric surgery. Their postoperative development seems to be associated with Helicobacter pylori-related gastritis or abuse of nicotine, alcohol or non-steroidal anti-inflammatory drugs (NSAIDs), but is also dependent on the choice of surgical method (Roux-en-Y or B-II gastric bypass). PATIENTS AND METHODS: This study evaluated the follow-up of 1,908 patients over a period of 5 years (January 2006–December 2010). In 1,861 cases, we performed a Roux-en-Y gastric bypass, and in 47 cases a B-II gastric bypass. RESULTS: All patients (n = 407) with symptoms such as dysphagia, reflux, nausea, vomiting or epigastric pain underwent gastroscopy. In 52 cases, ulcers were found at the gastrojejunostomy site. Of these patients, 39 (75%; p < 0.0001) had consumed alcohol, nicotine or NSAIDs; in 14 patients (27%; p < 0.0001) we detected H. pylorirelated gastritis. A total of 2.4% of the patients after Roux-en-Y gastric bypass (45/1,861) and 14.9% of the patients after B-II gastric bypass (7/47) developed ulcers at the gastroenteral junction. The difference is clearly significant (Fisher's exact test, p = 0.0002). Furthermore, there were significant differences regarding the recurrence rate: 86% of the B-II gastric bypass group and 13.3% of the Roux-en-Y gastric bypass group needed to be treated several times. CONCLUSIONS: Every patient needs to be informed preoperatively that there is a markedly increased risk of ulcers at the gastroenteral junction, particularly if the patient cannot avoid potential risk factors (nicotine, alcohol, NSAIDs). Preoperative gastroscopy with H. pylori testing and subsequent eradication can also reduce the risk of ulcers. An increased incidence of peptic ulcers after B-II gastric bypass was noted. All of these patients were converted to Roux-en-Y. more...

HINTERGRUND: Der temporÄre Einsatz eines Magenballons zur Behandlung der Adipositas Grad1 und 2 nimmt weltweit zu; bei der Adipositas Grad 3 wird der Magenballon als adjuvantes Hilfsmittel zur prÄoperativen Gewichtsreduktion implantiert. Ziel dieser retrospektiven Kohorten analyse ist, die Wirksamkeit des Magenballons auf Gewichtsreduzierung und das Risikoprofil der Methode zu evaluieren. METHODEN: Retrospektive Kohortenanalysen aus 4 Adipositas-Zentren, in denen der Magenballon seit 2001 regelmÄßig implantiert wurde. ERGEBNISSE: Von Februar2001 bis April 2008 wurde bei 634 Patienten ein Magenballon implantiert (BIBTM Intragastric Balloon System; Allergan Medical, Irvine, CA, USA). Die Geschlechterverteilung war 31,5% MÄnnerzu 68,5% Frauen; das Durchschnittsalter betrug 41,5 Jahre. Das durchschnittliche Ausgangsgewicht lag bei 126 kg. Der initiale BMI bei Implantation des Magenballons war 42,5 kg/m(2). Die Implantation der Prothese war in allen FÄllen unkompliziert. Der durchschnittliche Gewichtsverlust lag bei 20,75 kg bzw. 7,05 BMI-Punkten. SUMMARY: The Gastric Balloon — a Retrospective Cohort Analysis with 634 Patients BACKGROUND: The temporary use of a gastric balloon for the treatment of obesity grade 1 and 2 is increasing worldwide, whereas in grade 3 obesity, it is implanted as a tool for preoperative adjuvant weight loss. The aim of this retrospective cohort analysis is to evaluate the effectiveness of weight reduction and to describe the risk profile of the method. METHODS: Retrospective cohort analysis of 4 obesity centers where gastric balloons had been regularly implanted since 2001. RESULTS: Between February 2001 and April 2008, the gastric balloon (BIBTM Intragastric Balloon System; Allergan Medical, Irvine, CA, USA) was implanted in 634 patients. The gender ratio was 31.5% males to 68.5% females; the average age was 41.5 years. The average initial weight was 126 kg. The initial BMI at implantation of the gastric balloon was 42.5 kg/m2. The implantation of the prosthesis was uncomplicated in all cases. Average weight loss was 20.75 kg or 7.05 BMI points, respectively. more...

Reoperations due to failures constitute an essential but challenging part of bariatric surgery practice today. The aim of this study was to evaluate the perioperative safety, efficacy, and postoperative quality of life in patients with biliopancreatic diversion (BPD), after failed vertical banded gastroplasty (VBG). Twelve patients after failed or complicated VBG, eight females and four males, median age 45 years (range 39–52), median body mass index (BMI) 46.39 kg/m2 (range 25.89–69.37), who underwent conversion to BPD, were studied. Ten patients due to weight regain and two patients because of severe stenosis of the gastric pouch outlet were submitted in conversion to BPD. In eight (66.6%) patients the primary VBG had been followed by at least one revisional operation due to inadequate weight loss. The 10 patients after failed VBG, reached the lowest BMI recorded after VBG in just a year after BPD (p = 0.721 for the comparison between the two time points). The two patients with stomal stenosis regained weight in the first six postoperative months and remain stable since then. Regarding safety, one major perioperative complication (gastrojejunostomy stenosis) occurred. At a median follow-up of 21 months (range 12–30) six complications have been documented, including a case of incisional hernia, four cases of pouch gastritis and a case of intractable iron-deficiency anemia. Our early results indicate that conversion of failed VBG to BPD is highly effective with acceptable morbidity. Our data show that the effect on weight is strongly dependent on the indication for the conversion. Conversion to BPD, in such a group of patients, is a wise alternative, since it may reduce operative risks. more...

Minimally invasive bariatric procedures next to becoming more and more popular have established a new field of applications for carbon dioxide (CO(2)) insufflators. In laparoscopic bariatric procedures, gas isused toinsufflate the peritoneal cavity and increase the intra-abdominal pressure up to 15 mm Hg for optima lexposure and a suitable operating field. The increased intra-abdominal pressure during pneumoperitoneum can reduce femoral venous flow, intra-operative urine output, portal venous flow, respiratory compliance, and cardiac output. However, clinical complications related to these effects are rare. Yet, surgeons should be constantly aware that the duration of an operation is an important factor in reducing the patient's exposure to CO(2) pneumoperitoneum and its adverse effects. The optimized performance of the bariatric high flow insufflator allows reaching stable abdominal pressure conditions quicker and at a higher level than a common insufflator. Therefore, high flow insufflators offer great advantages in maintaining intra-abdominal pressure and temperature in comparison to conventional insufflators and thus enhance laparoscopic bariatric surgery by potentially reducing the operating time and the undesirable effects of CO(2) pneumoperitoneum. more...

Patients who undergo bariatric operations are at high riskof venous thromboembolism (VTE), with the incidence ofperioperative pulmonary embolism (PE) estimated at .85–.9% [1,2]. VTE remains the leading cause of death of thebariatric surgical patient during the perioperative period [3].PE accounts for 50% of deaths after laparoscopic or opengastric bypass (Roux-en-Y gastric bypass [RYGB]) [4].The clinical severity of PE can be highly variable, rang-ing from asymptomatic to severe hypoxemia and shock.Massive PE, however, characterized by circulatory collapse,is rare, and, as such, randomized controlled trials on itsoptimal management are lacking. We present a case of thesuccessful use of thrombolytic therapy for acute massive PEin the immediate postoperative period after laparoscopicRYGB in a super-obese patient, highlighting the necessityfor prompt diagnosis and treatment. more...

Background: Intragastric balloon placement in association with diet for weight reduction is steadily gaining popularity. However, long-term follow-up studies on the effect of this method in maintaining weight loss are lacking. This study evaluated the long-term outcome following balloon removal in morbidly obese patients who had selected this method for weight loss. Methods: 140 morbidly obese patients who refused bariatric surgery because of fear of complications and mortality, underwent intragastric balloon placement and were followed over a 6- to 30-month period (mean 18.3 months) after balloon extraction. The 34 males and 106 females, with median age 38 years (range 16-62), median weight 122 kg (range 85-203), median BMI 42.3 kg/m2 (range 35-61.3) and median excess weight (EW) 59 kg (range 29-132), received a Bioenterics Intragastric Balloon (BIB). Excess weight loss (EWL) ≥25% when the BIB was removed was considered a success. Weight fluctuations and any further interventional therapy requested by the patients after balloon removal were recorded. Results: 100 patients (71.4%) lost ≥25% of their EW on balloon extraction and were categorized as successes, while 40 patients (28.6%) did not achieve that weight loss and were categorized as failures of the method. During the follow-up period, 44 of the originally successful patients (31.4%) regained weight and were categorized as recurrences, while the remaining 56 patients (40%) maintained their EWL of ≥25% and were considered long-term successes. During follow-up, 45 patients (32.1%) requested and underwent bariatric surgery for their morbid obesity (21 Adjustable Gastric Band, 11 Laparoscopic Sleeve Gastrectomy, 13 Laparoscopic Gastric Bypass). Of these, 13 (32.5%) were from the group of 40 patients categorized as failures on BIB removal, 28 (63.6%) were from the group of 44 patients whose obesity recurred, and 4 (7.1%) were from the 56 patents who although they maintained successful weight loss requested further weight reduction. Conclusions: The BIB served as a first step and a smooth introduction to bariatric surgery for morbidly obese patients who initially refused surgical intervention. The incidence of surgical intervention was double in patients who initially experienced the benefits of weight loss and then had obesity recurrence, compared with patients in whom the method failed. Indeed, a significant number of patients were assisted in their efforts to lose and maintain an acceptable weight loss over a 6- to 30-month follow-up period. more...

We report a very unusual case of malignant sigmoidoduodenal communication. To the best of our knowledge, this is the first documentation of this entity in the English language literature. A 76-year-old man presented with weakness, severe weight loss, foul-smelling eructations, anemia, constipation, and episodes of diarrhea. A sigmoidoduodenal fistula was found by barium enema, and a diagnosis of ulcerative colonic adenocarcinoma was made from the colonoscopy findings. Thus, we performed sigmoid colectomy with resection of the fistula and the involved anterior wall of the third duodenal part, followed by primary closure of the duodenal defect. Histological examination confirmed a Dukes' B (Stage II - T(4)N(0)M(0)) colonic adenocarcinoma, and the excision margins of the resected duodenal specimen were clear. We gave adjuvant chemotherapy with 5-fluorouracil and leucovorin. The patient is still alive and disease-free, 2 years postoperatively. more...