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Aim: Aim of our study was the evaluation of Italian experience with bilio-intestinal bypass in the surgical treatment of morbid obesity., Materials and Methods: 1030 patients; mean age 36.1 years; preoperative mean weight Kg 136.7; mean preoperative BMI 48.9 kg/m2; mean follow-up 68 years (1-28). 838 patients underwent open and 192 laparoscopic bilio-intestinal bypass. The laparoscopy operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler., Results: Weight loss was satisfactory in 93% of operated patients. Comorbidities (arterial hypertension, diabetes, sleep apnea syndrome) solved in majority of the patients. The main late complications were incisional hernia in open technique and oxalic nephrolithiasis. The reversal rate was 2.5%., Conclusion: Our experience showed that bilio-intestinal bypass can obtain good results. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

Background: Since 1990 we adopted the bilio-intestinal bypass (BIBP) for all morbid obese patients eligible to a malabsorption procedure. Since 2001 we used laparoscopic technique., Materials and Methods: 102 patients; mean age 35.4 (18-54) years; preoperative mean weight Kg 148.3 (105-225); mean preoperative BMI 54.1 kg/m2 (40-66.2); mean follow-up 10 years (1-22). 83 patients underwent open and 19 laparoscopic BIBP. The operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz and of mesentery was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler. On the excluded ileum an anti-reflux valve system was hand-sutured., Results: Five years post-operatively mean weight was 89 (62-130) kg, mean BMI was 31 (24-41) kg/m2. Two patients of the 19 laparoscopic patients were converted in open surgery for adhesions post-appendectomy. The main late complications were incisional hernia (19.3%) and abdominal bloating (2.9%). The reversal and conversion rate was 65%. There was no death., Conclusion: Our experience showed that five years post-BIBP the weight loss was satisfactory in 90.7% of patients. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

Background: The adjustable gastric banding is considered the most common procedure in Europe for the treatment of morbid obesity. We report our experience with this procedure, that was introduced in our Departments of Surgery since 1993., Methods: From December 1993 to December 2004, 684 morbid obese patients (139 males and 545 females) underwent adjustable gastric banding (AGB) in our departments of Surgery. The first 323 patients were operated with perigastric procedure, the following 361 patients with pars flaccida technique. 601 patients were operated with laparoscopic approach, 83 with open approach. The average follow-up is 5 years., Results: Mean BMI decreased from 42.2 to 34 Kg/m2 five years after the operation, with an EWL of 54 %. The main early complications were: intraoperative gastric perforation (5 patients, 1 of which repaired in laparoscopy); hemorrhage from short gastric vessels (3 patient, repaired in laparotomy). The major late complications were: intragastric band migration (7 patients); irreversible dilatation of the gastric pouch (42 patients, treated surgically with band removal or repositioning)., Conclusion: In our experience laparoscopic adjustable gastric banding is a safe and effective procedure, suitable to most patients, and should be considered as the first choice in the surgical treatment of morbid obesity.

Introduction: Since 1998, we adopted in our clinical practice for obesity treatment the new intragastric balloon (BioEnterics Intragastric Balloon, BIB), it has the characteristics of an "ideal gastric balloon" (Workshop Tarpon Springs, 1987)., Materials and Methods: Since March 1998 we have placed by endoscopic approach 518 BIB in 480 patients affected by first, second and severe morbid obesity; 124 male and 356 female, mean age 41.6 years (18-72), mean weight Kg 116.9 (67-229), mean BMI 42 Kg/m2 (27.34-81.14). All our patients underwent to diet of 1000 Kcal/day and treatment with antisecretory drugs., Results: The mean weight lost was Kg 14.69 and the mean reduction in BMI was 5.11 Kg/m2. Weight loss was greater in male severe obese (BMI > 40). Weight was accompanied by an improvement of the disease associated with obesity, in particular diabetes, hypertension and sleep apnoea., Discussion and Conclusion: The best indication for BIB were: morbidly obese patients (BMI > 40) and super-obese patients (BMI > 50) in preparation for bariatric operation; obese patients with BMI 35-40 with co-morbilities in preparation for bariatric surgery; obese patients with BMI < 30 only in a multidisciplinary approach patients with BMI 30-35 with a chronic disease otherwise unresolved.

Background: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure., Methods: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place., Results: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement., Conclusion: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.

Background: Little is known about obesity surgery in young and adolescent patients. The aim of this study is to evaluate results of laparoscopic adjustable gastric banding in obese teenagers., Methods: Patients < or = 19 years old selected from the database of the Italian Collaborative Study Group for Lap-Band were analyzed according to mortality, comorbidities, laparotomic conversion, intra- and postoperative complications, body mass index (BMI), and % excess weight loss (EWL) at different times of follow-up. Data were expressed as mean +/- SD., Results: Fifty-eight (1.5%) of 3813 patients who underwent operation with the Lap-Band System were < or = 19 years old: 47F/11M; mean age, 17.96 +/- 0.99 years (range, 15-19); mean BMI, 46.1 +/- 6.31 Kg/m2 (range, 34.9 - 69.25); mean % excess weight, 86.4 +/- 27.1 (range, 34 - 226.53). Sixteen (27.5%) of the 58 patients were superobese (BMI > or = 50). In 27/58 (46.5%) patients, 1 or more comorbidities were diagnosed. Mortality was absent. Laparotomic conversion was necessary in 1 patient with gastric perforation on the anterior wall. Overall postoperative complications occurred in 6/58 (10.3%). The band was removed in 6/58 (10.3%) patients for gastric erosion (3 patients), psychologic, intolerance (2 patients), and in the remaining patient was converted 2 years after surgery (BMI 31) to gastric bypass or gastric pouch dilatation. Patient follow-up at 1, 3, 5, and 7 years was 48/52 (92.3%), 37/42 (88.1%), 25/33 (75.7%), and 10/10, respectively. At these times, mean BMI was 35.9 +/- 8.4, 37.8 +/- 11.27, 34.9 +/- 12.2, and 29.7 +/- 5.2 Kg/m2. Mean %EWL at the same time was 45.6 +/- 29.6, 39.7 +/- 29.8, 43.7 +/- 38.1, and 55.6 +/- 29.2. Five/25 (20%) patients had < or = 25% EWL at 5 years follow-up, while none of the 10 patients subject to follow-up at 7 years had < or = 25% EWL., Conclusions: Lap-Band System is an interesting option for teenagers suffering obesity and its related comorbidities, which deserves further investigation.

Background: The temporary use of the BioEnterics Intragastric Balloon (BIB) in morbidly obesity is increasing worldwide. The aim of this study is the evaluation of the efficacy of this device in a large population, in terms of weight loss and its influence on co-morbidities., Methods: Data were retrospectively recruited from the data-base of the Italian Collaborative Study Group for Lap-Band and BIB (GILB). After diagnostic endoscopy, the BIB was positioned and was filled with saline (500-700 ml) and methylene blue (10 ml). Patients were discharged with diet counselling ( approximately 1000 Kcal) and medical therapy. The BIB was removed after 6 months. Positioning and removal were performed under conscious or unconscious sedation. Mortality, complications, BMI, %EWL, BMI loss and co-morbidities were evaluated., Results: From May 2000 to September 2004, 2,515 patients underwent BIB (722M/1,793F; mean age 38.9+/-14.7, range 12-71; mean BMI 44.4+/-7.8 kg/m(2) ; range 28.0-79.1; and mean excess weight 59.5+/-29.8 kg, range 16-210). BIB positioning was uncomplicated in all but two cases (0.08%) with acute gastric dilation treated conservatively. Overall complication rate was 70/2,515 (2.8%). Gastric perforation occurred in 5 patients (0.19%), 4 of whom had undergone previous gastric surgery: 2 died and 2 were successfully treated by laparoscopic repair after balloon removal. 19 gastric obstructions (0.76%) presented in the first week after positioning and were successfully treated by balloon removal. Balloon rupture (n=9; 0.36%) was not prevalent within any particular period of BIB treatment, and was also treated by BIB removal. Esophagitis (n=32; 1.27%) and gastric ulcer (n=5; 0.2%) presented in patients without a history of peptic disease and were treated conservatively by drugs. Preoperative co-morbidities were diagnosed in 1,394/2,471 patients (56.4%); these resolved in 617/1,394 (44.3%), improved (less pharmacological dosage or shift to other therapies) in 625/1,394 (44.8%), and were unchanged in 152/1,394 (10.9%). After 6 months, mean BMI was 35.4+/-11.8 kg/m(2) (range 24-73) and %EWL was 33.9+/-18.7 (range 0-87). BMI loss was 4.9+/-12.7 kg/m(2) (range 0-25)., Conclusions: BIB is an effective procedure with satisfactory weight loss and improvement in co-morbidities after 6 months. Previous gastric surgery is a contraindication to BIB placement.

Background: Laparoscopic of the LAP-BAND System placement stage of obesity is a safe operation, but its indication in terms of stage of obesity is controversial. The aim of this study was to evaluate the 5 years stage of obesity results for weight loss in patients with varying preoperative ranges of body mass index (BMI)., Methods: Data were obtained from the Italian Collaborative Study Group for LAP-BAND System (GILB) registry. Detailed information was collected on a specifically created database (MS Access 2000) for patients operated on in Italy from January 1996 to 2003. Patients operated on between January 1996 and December 1997 were allocated to four groups according to preoperative BMI range: 30-39.9 kg/m(2) (group A), 40-49.9 kg/m(2) (group B), 50-59.9 kg/m(2) (group C), and =60 kg/m(2) (group D) percent estimated weight loss respectively. Postoperative complications, mortality, BMI, BMI loss, and (%EWL) were considered in each group. Data are expressed as mean +/- SD, except as otherwise indicated. Statistical analysis was done by means of Fisher's exact test, and p < 0.05 was considered significant., Results: After 5 years from LAP-BAND System surgery, 573 of 3,562 patients were eligible for the study. One hundred fifty-five of 573 (27.0%) were lost to follow-up, 24 of 418 (5.7%) underwent band removal due to complications (gastric pouch dilation, band erosion), eight of 418 (1.9%) were converted to other bariatric procedures, five of 418 (1.2%) died of causes not related to the operation or the band, and 381 of 573 (66.5%) were available for follow-up. Based on 96, 214, 64, and seven patients their preoperative BMI, Were allocated to groups A, B, C, and D, respectively. At time of follow-up mean BMI was 27.5 +/- 5.2 in group A, 31.6 +/- 4.7 in group B, 37.6 +/- 17.3 in group C, and 41.4 +/- 6.9 kg/m(2) in group D. Mean BMI loss was 9.8 +/- 5.4, 12.9 +/- 5.2, 15.8 +/- 8.1, and 23.2 +/- 4.9 kg/m(2), respectively, in groups A, B, C, and D. Mean %EWL at the same time was 54.6 +/- 32.3 in group A, 54.1 +/- 17.2 in group B, 51.6 +/- 35 in group C, and 59.l +/- 17.1 in group D., Conclusion: Initial BMI in this series did not correlate with %EWL 5 years after the operation. In fact %EWL was almost the same in each group, independent of preoperative weight. Initial BMI was an accurate indicator of the results obtained 5 years after LAP-BAND in group C (50-59.9 kg/m(2)) and D (=60 kg/m(2)) patients, who remained morbidly obese despite their %EWL.

Background: The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) 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 < or = 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/m(2), 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/m(2) 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 < or = 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.

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.

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

Background: The BioEnterics Intragastric Balloon (BIB, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity., Methods: Since March 1998, 322 BIB were placed in 281 obese and morbidly obese patients; 73 patients were male and 208 female; mean age was 41.6 years (21-70); mean weight was 117.4 kg (67-229); mean BMI was 41.8 kg/m2 (29-81); % excess weight was 62% (10-216). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 kcal/day. Also, for 18 months we compared 42 obese patients treated only with 1000 kcal/day diet (group A) with 31 obese patients subjected to BIB for 4 months + 1000 kcal/day diet (group B)., Results: After 4 months of balloon treatment, the mean weight loss was 13.9 kg and the mean reduction in BMI was 4.8. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes. In the diet vs BIB + diet study, BIB with diet produced a greater weight loss in a shorter time than diet alone., Conclusion: The best indications for BIB were: morbidly obese opatients (BMI > 40) and super-obese patients (BMI > 50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbilities 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: 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 occurred 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.

Background: Since March 1998, 143 BioEnterics Intragastric Balloons (BIB) were placed in 132 obese and morbidly obese patients, to study the clinical possibilities of a new system, both from the point of view of the materials used and the application method., Methods: 36 patients were male and 96 female; mean age was 43 years (21-70); mean weight was 115.4 kg (67-229), and mean BMI was 41.0 (29-81). 8 patients were affected by severe respiratory insufficiency. We placed and removed the balloon endoscopically under conscious sedation or general anesthesia. BIB was removed in the majority of patients 4 months after insertion. The patients were given a balanced diet of 800-1000 kcal/day; follow-up involved a monthly check-up (routine blood tests, weight control) and a visit every 15 days with the dietitian., Results: Mean weight loss was 14.4 kg; mean reduction in BMI was 5.2. Weight loss was much better in males. The weight loss produced an improvement of the complications associated with the obesity. Complications observed were: balloon intolerance (9 early removals), 1 balloon deflated and passed, 2 cases of gastric ulcer at balloon removal., Conclusions: The most correct indications for BIB should be: extremely obese patients (BMI>40) in preparation for a bariatric operation; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI<30 in a multidisciplinary approach.

Background: From 1993 to 1999, 172 patients underwent adjustable silicone gastric banding (ASGB) or laparoscopic adjustable silicone gastric banding (LASGB). In 109 patients the adjustable band was placed via laparoscopy; in the other patients it was placed via laparotomy (prelaparoscopic era, conversions from other bariatric operations, conversions for laparoscopic failure). The conversion rate from laparoscopy to laparotomy was 9.3%, occurring in the early part of our experience., Methods: Mean age was 37.9 years, weight 135 +/- 14.8 kg (82-218) and BMI 46.3 +/- 5.4 (35.1-69.5). All patients had multiple band adjustments, temporary antisecretive, electrolyte and vitamin therapy, and follow-up per routine., Results: Weight loss at 3 years was 30.2%; mean percent loss of excess weight was 62.5%. There was no mortality. The most important technical complications were: gastric pouch dilatation that required band replacement or removal (5.8 %); mild gastric pouch dilatation reversible with adequate dietary and pharmacological treatment (4.6%); intraoperative gastric perforation (2.3%); band migration (0.6%). The band was removed in 2.3%, with conversion to another bariatric procedure in 1.1%., Conclusions: Results have been satisfactory thus far.

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.

Background: The detection of cervical lymph node metastases plays an important role in staging of patients affected by esophageal cancer to perform the best therapeutic approach., Methods: We report our experience concerning the ultrasound evaluation of the cervical area in 174 patients with esophageal cancer. Ultrasonographic evaluation of the neck can be done with a 7.5- or 10 MHz transducer in all cases, with selective scanning of the lymph node chains of the internal jugular veins and supraclavicular regions. The short-to-long axis ratio (S/L) was a useful way to detect lymph node metastasis. Histopathologic diagnoses were obtained by sonographically guided fine-needle aspiration biopsy., Results: At ultrasound examination, we found 18 (10.3%) patients with metastatic cervical nodes. Of these, 17 (94.4%) had metastatic cervical lymph nodes confirmed by cytology from fine-needle biopsy. Lymph node exceeding 5 mm in long axis and with an S/L over 0.5 showed a higher incidence of metastasis than those with an S/L under 0.5. Our experience shows a high incidence of lymph node metastases in patients with esophageal cancer localized to the thoracic supracarinal tract and in patients with cervical and lower esophageal cancer., Conclusion: In the ultrasound evaluation of nodes, the most useful parameters are size of nodes, heterogeneity of internal echoes, morphology of the margins, and the deformation caused by compressive instrumental manipulation. These criteria, indicated by the Japanese Society for Esophageal Diseases, yield a high sensitivity and diagnostic specificity when the ultrasonographic studies are performed.

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.

To study why the symptoms of abdominal bloating occurring in a number of patients after jejuno-ileal bypass for morbid obesity become resistant to antibiotics, we used a method which combined a hydrogen breath test after lactulose with an X-ray examination of the abdomen after barium. Ten operated patients with bloating symptoms resistant to antibiotics, ten operated patients without symptoms or with pre-existing symptoms, that had remitted after antibiotic treatment and ten nonoperated obese controls were investigated. There was a significant correlation between post-surgical symptoms persisting after antibiotics and the exhalation of large amounts of hydrogen of colonic origin (> 100 parts per million) after lactulose. Furthermore, symptomatic patients had high prevalence of colonic motility disorders (slow transit). In these patients, treatment with a prokinetic (cisapride 40 mg/kg/day for 10 days) reduced colonic transit time, colonic hydrogen production and bloating symptoms. Abdominal symptoms in these patients may therefore have other causes than small bowel bacterial overgrowth alone. All operated patients with persistent abdominal bloating should therefore be investigated before starting empirical treatment with antibiotics.

Intestinal microflora settlement was evaluated in this retrospective study of 49 patients with jejunoileal bypass who required reoperation. Colonic microflora was observed in the samples of the contents of the functioning jejunum and ileum but not in 55% of the samples from the middle of the excluded loop. Colonization of the excluded loop was not detected in patients without clinical signs of bacterial overgrowth but was significantly frequent (p < 0.01) in those with clinical signs (bloating, migratory arthralgias, rashes, skin lesions). However, positive excluded loop cultures were not always associated with clinical manifestations. No significant correlation was observed between bacteriology of the contents of the excluded loop and bypass results. The success of an intestinal bypass may depend not only on anatomic and functional adaptation to the new, surgically created conditions, but also to the attainment of microbiological equilibrium in the intestinal ecosystem.

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.

Since 1954 the aim of surgical treatment of severe obesity has been to perfect a specific treatment capable of obtaining a massive, long-lasting and well tolerated loss of weight in severely obese subjects in which different and repeated attempts using conservative medicine have proved inefficacious or non-resolutive. During the course of almost 40 years, bariatric surgery has gradually evolved in the search for the "ideal" surgical treatment: for this purpose, operative methodologies and techniques have been proposed and experimented using differing physiopathological concepts and means of application. After a brief analysis of the history of bariatric surgery, there is a short summary of the most internationally widespread surgical methods and the most recent techniques now used for the surgical treatment of severe obesity based on the Authors' ten year experience of 321 intestinal bypasses (jejuno-ileal and biliointestinal), 110 horizontal gastroplasties and 23 vertical gastroplasties with a silastic ring. Intestinal bypass almost always allows sufficient weight loss to be achieved (85% of operated patients lose 80% of excess body weight) and the various postoperative problems of differing degrees of severity can be prevented by adequate replacement therapy and regular outpatient monitoring. Gastroplasties lead to a slightly smaller loss of weight (73% of excess body weight) within a shorter period of time, with fewer postoperative problems, but at the expense of a drastic and continual reduction in food intake. All patients operated require intense and long-term postoperative follow-up carried out by experts in order to achieve the desired results.

The changes in functional and excluded loops were studied in two groups of patients at intervals up to 5 years after jejuno-ileal bypass. Macroscopic and histological observations confirmed that the compensatory increase of the absorbing surface of the functioning loop occurs, with an increase in length and width of the loop, hypertrophy of villi and microvilli, and increase in number and geometrical surface of the villous cells. In the excluded intestinal loop, atrophy occurs, evidenced by the reduction in number and size of microvilli, even if the height of villi may appear normal. The bacteriological studies of the functioning and excluded loops show bacterial colonization, which was not constant over the course of time.

Indications and procedures of restorative proctocolectomy in the surgical treatment of ulcerative colitis and familial polyposis are reported. Surgical procedure and some technical innovations are discussed.

The use of inflatable intragastric balloons is a new non-intensive approach in the treatment of obesity when poor results are obtained by more conservative treatment. The intragastric balloons are certainly less hazardous than bariatric surgery but their long term effect on body-weight reduction it is not still proved. Several types of balloons are currently in use. The two used most widely are the Garren-Edwards Gastric Bubble and the Ballobes Balloon. The Authors report their experience with these two types of anti-obesity gastric-balloon in 60 grossly obese patients.

Changes in the lipid picture of 28 grossly obese subjects induced by jejunoileal by-pass are described. The results indicate that this operation brings about a marked reduction in total cholesterol and triglycerides, and hence a distinct regression of risk factors with regard to atherosclerosis.

In 6 of our patients operated upon for pathological obesity, complete recanalization of the jejunum closed by a mechanical suture upstreams of the jejuno-ileal latero-lateral anastomosis resulted in failure of the intestinal bypass. We have modified our technique and instead of closing the jejunum with a mechanical stapler we now divide it, then bury and attach together its two ends to avoid torsion and invagination. The operation is completed by creating an anti-reflux system at the terminal end of the excluded ileum.