Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006

BACKGROUND

Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery.

MATERIALS AND METHODS

All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial.

RESULTS

In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%).

CONCLUSION

Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.

[Antegrade aortomesenteric revascularisation originating from the supracoeliac aortic segment--a promising surgical option in chronic ischaemia of the visceral arteries]

INTRODUCTION

Ischaemia of the visceral arteries is considered to be an extraordinary challenge in the interdisciplinary therapeutic management.

AIM AND METHOD

Using a case series of patients with chronic ischaemia of the visceral arteries, our diagnostic and therapeutic experience was analysed with regard to postoperative quality of life (increase of body weight, frequency in daily diarrhoea), perioperative morbidity and hospital mortality in dependence on the type of surgical reconstruction of the visceral arteries.

RESULTS

During a time period of 2 years, 3 patients (male/female=1:2; mean age, 61.7 years) underwent surgical interventions on the visceral arteries from a total of 1118 vascular interventions (main indication revealed by colonoscopy and pathohistology of mucosal biopsy: ischaemic colitis). In all cases, symptomatology was affected by abdominal angina. Duplex sonography, angiography, and multislice CT scan revealed the combination of an occlusion of the coeliac trunk and of the superior mesenteric artery by atherosclerosis in 2 cases. In the remaining case, there was an isolated occlusion at the origin of the superior mesenteric artery. For revascularisation, the aortomesenteric reconstruction was subdivided according to the: i) target vessel: -combination of revascularised common hepatic artery and superior mesenteric artery (n=1) with an autologous Y-vein bypass ("reversed technique"), -exclusive revascularisation of the superior mesenteric artery (n=2)-prosthetic bypass; ii) origin of the bypass: -from the supracoeliac aortic segment (antegrade) n=3 (primarily in patients 1 and 3; as a redo operation in patient 2); -from the infrarenal segment (retrograde) n=1 (initial surgical intervention in patient 2) using an autologous venous bypass. In all cases, a significant improvement of the quality of life was observed as indicated by an increase of body weight (n=3; +no further abdominal angina) and primary wound healing in all 3 cases (hospital mortality, 0).

CONCLUSION

Chronic ischaemia of the visceral arteries is characterised by an increasing incidence and a stealthy onset and requires an interdisciplinary approach to find the correct diagnosis using all available diagnostic procedures including sufficient periodic follow-up investigations. We favour the antegrade aortomesenteric revascularisation from the supracoeliac aortic segment as a promising surgical option in chronic ischaemia of visceral arteries.

[The spectrum of war-like injuries in children and teenagers during a post-war wave of violence in Iraq]

BACKGROUND

In developing countries, war-like injury involving civilians, including children, is still a relevant and massive health problem and the human and economic costs of the injuries are tremendous.

OBJECTIVE

The aim of this study is to report on the spectrum of war-like injuries and their management in children and teenagers in an Iraqi surgical centre during a post-war wave of violence.

PATIENTS AND METHODS

All consecutive war-like injuries in children and teenagers younger than 16 years were documented in a clinical observational study (study design: Case series), who were treated during the time period of employment of the reporting author at the Casualty Unit of the University Hospital in Al Kadhimiyia (UHK), Baghdad (Iraq), over a 2-year period. The cases were studied with regard to descriptive criteria such as demographic patient characteristics, cause, site(s), and combination of injuries as well as their surgical management; among other factors, the specialty-depending distribution and outcome characterised by mortality were evaluated. Representative photographs have been selected from the photographic documentation in most cases.

RESULTS

From March 2003 to March 2005, 272 injured children and teenagers aged 16 years or less were enrolled in the study. The injuries in the majority of the casualties were caused by explosions in civilian areas, mortar bombardment of civilian buildings and housing, and family assassinations. The injuries were more common in males with a male to female ratio of 3.1 : 1; 206 (75.7 %) of the casualities were males and 66 (24.3 %) were females. Of the 272 casualties studied, 52 (19.1 %) were 5 years old or less, 95 (34.9 %) were between 6 to 11 years, and 125 (45.9 %) were between 12 to 16 years old. There were 126 (46.3 %) minor casualties, who were managed in the outpatient emergency unit, while 146 (53.6 %) casualties had serious and major injuries, 120 (44.1 %) of whom were admitted to UHK and 6 were transferred to other hospitals. Twenty (7 %) casualties died (12 on arrival and 8 during resuscitation) and two casualties were discharged at their parents demand shortly after admission without receiving adequate medical care. Fragmentation weapons (blast injuries) caused 216 (79.4 %) casualties, 54 (19.8 %) casualties experienced gunshot wounds and 2 (0.7 %) substantial burns. Injuries to the lower limbs and trunk were the most common injuries in this series accounting for 126 (46.3 %) of all injuries.

CONCLUSION

There is a considerable risk not only for adolescents but even for children under conditions similar to those of civil war. However, the challenge is to provide an appropriate treatment in spite of the potential severity of injuries. This requires an adequate logistic management, surgical expertise as well as equipment and even the collaboration with surgical centres from supporting countries.

Surgery of inferior vena cava associated malignant tumor lesions

BACKGROUND

Tumor lesions of the inferior vena cava (IVC) can originate from the vein or can develop by malignant tumor infiltration from the surrounding tissue. In this context, particular attention should be paid to tumor lesions with pegs into or within the IVC. The aim of this series of a single surgical center was to analyze the perioperative management, the individual-specific and -adapted surgical technique, as well as the outcome including prognostic considerations in IVC-associated malignant tumor lesions.

PATIENTS AND METHODS

Over a 6-year time period, all consecutive patients with IVC-associated malignant tumor lesions and their patient- and finding-specific characteristics were registered, data and parameters of the diagnostic and therapeutic management were documented, and both the short- and long-term outcomes (complication rate, perioperative morbidity/mortality, tumor recurrence rate, survival) were assessed with periodic follow-up investigations.

RESULTS

Overall, 12 patients were enrolled in the study from 1/1/2001-31/12/2006:6 primary IVC-tumors (leiomyosarcomas, 50%) and 6 secondary IVC-tumors (2 retroperitoneal tumor lesions, 16.7%, 3 renal cell carcinomas 25% and 1 carcinoma of the adrenal gland, 8.3%). 4 of the secondary tumors had pegs into the IVC. The RO resection rate was 83%. The perioperative morbidity was 33%; whereas, the hospital mortality was 8.3% (n = 1). Surgical reconstruction of IVC was achieved in each case (100%). There was a mean postoperative observation period of 20 months (range, 1-58 months). Complete follow-up documentation was obtained for all of the patients (100%). Three patients experienced recurrent tumor growth (27.5% out of n = 11). While the overall mortality through the follow up observation period was 27.5%, the tumor-specific mortality was 16%.

CONCLUSIONS

The primary surgical aim is RO resection to provide a long-term outcome with no tumor recurrence including the reconstruction of the IVC based on a reasonable risk-to-benefit ratio. The favorable outcome of this case series demonstrates that IVC-associated tumor lesions can be approached if there is an appropriate expertise of the surgical team, a sufficient perioperative management and an adequate financial background with a reasonable survival rate. The variable prognosis of the various tumor lesions depends on tumor entity, stage, resection status and individual risk factors.

Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation

PURPOSE

There is currently no imaging procedure that allows precise differentiation between inflammatory and malignant lesions of the papilla of Vater (papilla) in a satisfying manner. The aim was to study whether endoscopic ultrasonography (EUS) as an initial diagnostic step 1. may have the potential to distinguish between different tissue characteristics, such as tumor growth or inflammation of the papilla, because of its high resolution capacity and 2. is superior to the accuracy of histologic investigations of mucosal biopsies by means of a prospective collection and retrospective evaluation of the data.

PATIENTS AND METHODS

Between 1995 and 2002, a significant pathologic finding in the papilla and the peripapillary region was revealed using EUS in 311 patients (overall, 4,832 EUS investigations); the comparison of this suspicion with the results of histologic investigation was only possible in 183 subjects. In 133/183 patients, a biopsy for histologic investigation was not able to be obtained prior to the use of EUS. Diagnosis was set up using EUS, which tried to differentiate between benign or malignant lesions of the papilla. Histologic investigation of the 133 tumor lesions of the papilla became possible by taking deep transpapillary biopsies following papillotomy, papillectomy or by obtaining specimens from surgical resections.

RESULTS

Using EUS, differentiation between inflammatory and neoplastic lesions of the papilla or the peripapillary region was correct in 109 of 133 cases (82%), while suspected EUS-based diagnosis "papillitis stenosans" (inflammatory lesions of the papilla of Vater) in 4 subjects (3%) was corrected to adenoma and carcinoma, respectively (n=2 each) by histologic investigation. In 20 of 133 patients with suspected neoplastic lesions, inflammatory lesion of the papilla of Vater was detected resulting in an overall sensitivity of 92.3% and specificity of 75.3%.

CONCLUSIONS

EUS makes it possible to detect small intraampullary tumors and segmental thickening of the wall of the prepapillary biliary duct, which cannot be revealed by conventional imaging. In patients with biliary symptoms, EUS can reliably visualize and characterize a malignant lesion as a first diagnostic tool (detection rate, 82%) and may be considered the basis for subsequent diagnostic steps for verifying diagnosis correctly, e. g., using histologic investigation.

[Acute blepharoptosis caused by fibrous dysplasia]

We report a case of fibrous dysplasia revealed by acute ptosis in a 38-year-old patient. Ophthalmologic examination disclosed a moderate right ptosis. The rest of the results were strictly normal except for a known facial asymmetry. Visual acuity was 20/20 in both eyes, there was no extrinsic or intrinsic oculomotor disorder, and funduscopy was normal. Given this acute presentation, emergency cerebral imagery was carried out, providing a diagnosis of fibrous dysplasia with orbital and cavernous repercussions, with no sign of cerebral disorder or obvious vascular lesion. Progression was marked by a regression of the ptosis. Fibrous dysplasia is a rare pathology but presents varied clinical presentations. The authors present the broad characteristics of this pathology and the management of an acquired ptosis. They discuss the possible mechanisms involved in the drop of the right upper eyelid of this patient and the therapeutic solutions.

Differential influence of the ventral subiculum on dopaminergic responses observed in core and dorsomedial shell subregions of the nucleus accumbens in latent inhibition

It has previously been reported that dopamine (DA) responses observed in the core and dorsomedial shell parts of the nucleus accumbens (Nacc) in latent inhibition (LI) are dependent on the left entorhinal cortex (ENT). The present study was designed to investigate the influence of the left ventral subiculum (SUB) closely linked to the ENT on the DA responses obtained in the Nacc during LI, using an aversive conditioned olfactory paradigm and in vivo voltammetry in freely moving rats. In the first (pre-exposure) session, functional blockade of the left SUB was achieved by local microinjection of tetrodotoxin (TTX). In the second session, rats were aversively conditioned to banana odor, the conditional stimulus (CS). In the retention (test) session the results were as follows: (1) pre-exposed (PE) conditioned animals microinjected with TTX, displayed aversion toward the CS; (2) in the core part of the Nacc, for PE-TTX-conditioned rats as for non-pre-exposed (NPE) conditioned animals, DA levels remained close to the baseline whereas DA variations in both groups were significantly different from the DA increases observed in PE-conditioned rats microinjected with the solvent (phosphate-buffered saline (PBS)); (3) in the shell part of the Nacc, for PE-TTX-conditioned rats, DA variations were close to or above the baseline. They were situated between the rapid DA increases observed in NPE-conditioned animals and the transient DA decreases obtained in PE-PBS-conditioned animals. These findings suggest that, in parallel to the left ENT, the left SUB controls DA LI-related responses in the Nacc. The present data may also offer new insight into the pathophysiology of schizophrenia.

Aneurysmaausschaltung am Iliakalarterienstumpf nach Bifurkationsprothesen-Implantation

Die interventionelle Radiologie zeigt bei gefäßmedizinischen Fragestellungen ein Spektrum von Indikationen. Mittels Punktion der A. femoralis dextra in Seldinger-Technik wurde interventionell-radiologisch unter Fluoroskopie- Führung suffizient ein Aneurysma des A.-iliaca-communisdextra- Stumpfes mittels Coil-Embolisation exkludiert. Die Komplikation einer iatrogen induzierten Blutung aus dem Aneurysmahals wurde mit Okklusionsemulsion gestoppt. Interventionell-radiologische Maßnahmen erlauben ein minimal-invasives Herangehen an einst klassische gefäßchirurgische Operationen. Ebenso werden Komplikationen der bildgeführten interventionellen Radiologie beherrschbar.

Impact of anastomotic leakage on oncological outcome after rectal cancer resection

BACKGROUND

: Anastomotic leakage has a major impact on morbidity and mortality in rectal cancer surgery. Its relevance to oncological outcome is controversial. This observational study investigated the influence of anastomotic leakage on oncological outcome.

METHODS

: Data for 1741 patients undergoing curative resection of rectal cancer (located less than 12 cm from the anal verge) with normal healing were compared with those for 303 patients who experienced anastomotic leakage. Morbidity, mortality and long-term oncological outcomes were analysed.

RESULTS

: Median follow-up was 40 months. Patients with anastomotic leakage had a higher postoperative mortality rate than those with no leakage (4.3 versus 1.2 per cent; P < 0.001). Patients with leakage necessitating surgical treatment had a higher 5-year local recurrence rate (17.5 versus 10.1 per cent; P = 0.006) and a lower 5-year disease-free survival rate (70.9 versus 75.4 per cent; P = 0.020) than those without leakage. Patients with anastomotic leakage not requiring surgical intervention did not have a worse oncological outcome.

CONCLUSION

: A negative prognostic impact of anastomotic leakage on local recurrence and disease-free survival was found only for patients with leakage needing surgical revision.

[Magnitude and strategies of cataract management in the world]

Although cataracts cause 47% of global blindness, their epidemiologic impact in different countries is notoriously uneven and the world can be divided into two zones according to economic conditions. In advanced countries where care is good, cataracts account for only 5% of blindness while cataracts still account for 50% of blindness in developing countries. After a brief overview of historical, clinical and therapeutic aspects, this article updates epidemiological data on cataracts in the world. It also provides insight into political, socio-economic, and cultural factors adversely affecting care availability in developing countries thus making cataracts a major public health problem and an obstacle for development. Finally this article offers a few recommendations for reducing the backlog of cataracts in the world and for consolidating advances made over the last two decades thanks to experience gained in various National Blindness Prevention Programs (NBPP).

[Conjunctival melanoma at corneoscleral limbus on primary acquired melanosis. A case report]

A 51-year-old Caucasian man consulted for a visual loss in the left eye due to corneal extension of a conjunctival melanoma. This conjunctival melanoma arose from primary acquired melanosis with atypia at the temporal corneoscleral limbus. The patient was treated using a combination of surgical excision with physical treatment by ocular proton therapy. Progression remained under control 11 months after treatment: no local tumour recurrence or metastasis was observed. Primary acquired melanosis with atypia must be regarded as a premalignant melanocytic lesion. Based on this case report, the authors focus on primary acquired melanosis and its risk of transformation to a conjunctival malignant melanoma.