The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

Nutritional Status, Selected Nutrients Intake, and Metabolic Disorders in Bariatric Surgery Patients

Bariatric surgery is the most effective treatment for obesity and its complications. However, failure to adhere to dietary recommendations can result in both unsatisfactory weight loss and metabolic disorders. The aim of this study was to evaluate the effects of bariatric surgery on the anthropometric parameters and selected nutrient intake. A total of 12 months postoperatively, percent excess weight loss (%EWL) was significantly higher after laparoscopic Roux-en-Y gastric bypass (LRYGB) than laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) (93.78% vs. 56.13% and 55.65%, p < 0.001). The same was true for waist-to-hip ratio (WHR) (p = 0.017) and waist-to-height ratio (WHtR) changes (p = 0.022). There was a significant decrease in total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels after RYGB. A significant decrease (p < 0.05) in daily intake was found for energy (4278.4 kcal vs. 1355.17 kcal), sucrose (122.23 g vs. 38.22 g), dietary fiber (30.90 g vs. 14.20 g), eicosapentaenoic fatty acid and docosahexaenoic acid (EPA+DHA) (142.46 mg vs. 52.90 mg) and % energy from fats (42.43% vs. 35.17%), saturated fatty acids (SAFAs) (19.96% vs. 14.11%) and alpha-linolenic fatty acid (ALA) (0.87% vs. 0.69%). Energy intake and energy % from fats positively correlated with body weight (BW), waist circumference (WC), WHR, and WHtR, and negatively with %EWL. The percentage of unsaturated fatty acids positively correlated with WC and WHR. Energy intake correlated positively with serum triglycerides (TGs) and energy % from fats and carbohydrates. Despite significant weight loss, the patient's diet deviated from recommendations and may have contributed to metabolic disorders.

Effect of Significant Postoperative Complications on Decision Regret After Laparoscopic Sleeve Gastrectomy: a Case-Control Study

Background

Thus far, no data are available on decision regret about sleeve gastrectomy (SG), particularly in patients who experienced perioperative complications. This study aimed to assess whether patients with postoperative complications regret their decision to undergo laparoscopic SG more than patients with an uneventful postoperative course.

Methods

The study group comprised patients with complications after laparoscopic SG (cases). The control group comprised patients who did not experience any postoperative complications (controls). A telephone survey was conducted on all patients. Patients’ satisfaction regarding their decision to undergo surgery was assessed using the Decision Regret Scale.

Results

In total, 21 patients who experienced postoperative complications and 69 controls were included. The patients in the study and control groups achieved similar percentages of total weight loss (32.9 ± 11.9 vs. 33.8 ± 15.0, p = 0.717) and excessive body mass index loss (74.9 ± 30.7 vs. 73.1 ± 36.7, p = 0.398) at 1 year postoperatively. The difference in weight change at 12 months postoperatively was not significant in both groups. The mean regret scores in the study and control groups were 13.2 ± 1.2 (range, 28–63) and 13.3 ± 1.1 (range, 12–66) (p = 0.818), respectively. Moreover, no significant difference was found among patients who expressed regret between the study and control groups (regret score > 50; 4.76% vs. 4.35%) (p = 1.000).

Conclusion

This study suggests that patients with postoperative complications do not regret their decision to undergo SG more than patients with an uneventful postoperative course.

Graphical abstract

Bariatric tourists. Foreign bariatric patients treated in Poland - a survey based study

&lt;b&gt;Introduction:&lt;/b&gt; Bariatric procedures are becoming more popular worldwide. We present a current situation of foreign patients treated by high-volume bariatric surgeons in Poland in 2016. &lt;br&gt;&lt;b&gt;Material and Methods:&lt;/b&gt; We sent an online survey to twenty high-volume bariatric surgeons. The questionnaire regarded the year 2016. We asked for number and types of bariatric procedures performed or supervised, number of foreign bariatric patients, their qualification process, country of origin, types of procedure, and post-op recommendations. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; We received 9 surveys (45%). Five surgeons performed or supervised from 100 to 300 bariatric procedures, 2 performed or supervised over 300 procedures, 2 performed or supervised from 50 to 100 procedures. All of the respondents performed laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB), four carried out mini gastric bypass, two - gastric banding (LAGB), one - SADI-S and duodenal switch (DS). Six surgeons operated on the total of 64 foreign patients, mainly performing LSG, LRYGB and mini gastric bypass. Most of the patients were qualified based on international criteria [body mass index (BMI) over 40 kg/m&lt;sup&gt;2&lt;/sup&gt; or BMI over 35 kg/m&lt;sup&gt;2&lt;/sup&gt; with comorbidities]. United Kingdom was the most popular country of origin, followed by Germany, USA, Ireland and Sweden. Qualification for surgery was based on a personal visit. After surgery, 83.3% (n = 5) of the respondents gave out discharge documents in English, recommending long-term bariatric follow-up in the country of origin. Every respondent carried out 3-month personal follow-up of every foreign patient. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Foreign bariatric patients travelling to Poland are qualified for surgery according to known international standards. Most of the patients receive post-op discharge documents in English, with a 3-month follow-up performed by their surgeon. Further bariatric supervision in the country of origin is routinely recommended.

The Safety and Benefits of Laparoscopic Sleeve Gastrectomy in Elderly Patients: a Case-Control Study

INTRODUCTION

The advancement of minimal invasive techniques pushed the age limit for patients qualified for bariatric surgery.

AIM

The aim of the study was to evaluate the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in a cohort of patients aged 60 years or more, compared with a group of matched controls below 40 years old.

METHODS

The medical records of 856 patients were analyzed. Patients aged 60 years or older were identified as cases. Those below 40 years were identified as the controls. Cases were closely matched (1:1) with the controls by body mass index (BMI) (± 1 kg/m²) and presence or absence of hypertension and diabetes mellitus.

RESULTS

A 34 matched pairs were included in the study. There was no significant difference in the median operation length. No conversion from laparoscopic to open surgery was needed. The hospital length of stay was significantly longer in the study group (4.5 ± 1.9 vs 3.9 ± 1.5 days, p = 0.047). The complication, 30-day reoperation, and 30-day reoperation rates were comparable in both groups. There were no 30-day readmissions nor 30-day mortality. ΔBMI after 12 months was significantly lower in the study group (13.56 ± 6.05 vs 10.3 ± 4.89, p = 0.008) as well as %EBMIL (50.71 ± 25.94 vs 64.20 ± 23.29, p = 0.015).

CONCLUSIONS

The study suggests that LSG is a safe method of bariatric treatment in patients aged above 60 years. Even though weight loss may be lesser than in younger patients, it can still be considered satisfactory.

Assessment of health behaviors, nutritional behaviors, and self-efficacy in patients with morbid obesity

OBJECTIVES

The objective of the study was to assess the frequency of health and nutritional behaviors concerning emotional, habitual, and restrictive eating as well as to evaluate self efficacy in patientswith morbid obesity and determine the correlation between patients'BMI index and their health behaviors as well as self-efficacy.

METHODS

The study included 37 patients diagnosed with class two and three obesity, aged 18-62 (M = 39.94; SD = 12.20). Patients' BMI ranged from 36 to 60 kg/m2 (M = 43.50; SD = 5.36). Research tools used in the study: the Inventory of Lifestyle Behaviors (ILB), the Dietary Behaviors Questionnaire (DBQ), and the General Self-Efficacy Scale (GSES).

RESULTS

Patients with morbid obesity were characterized by medium (men; a sten score of 5) and low (women; a sten score of 4) intensity of health behaviors. Subjects showed a tendency for negative nutritional behaviors, emotional and habitual eating as well as dietary restrictions. General self-efficacy ranged between sten scores of 4 to 10, with mean at a high level (a sten score of 7).

CONCLUSIONS

Patients with morbid obesity need health, nutritional, and psychological education.

Bulimia nervosa in obese patients qualified for bariatric surgery - clinical picture, background and treatment

Eating is a basic human physiological need which is necessary to keep the body alive. Eating disorders are diagnosed when eating (or not eating) and associated body weight gain anxiety become the main interest of an individual and all other spheres of life depend on it. Bulimia nervosa is a psychiatric disorder which is more and more commonly diagnosed in patients suffering from obesity and in patients after surgical treatment of obesity. In patients eligible for bariatric surgery this disorder should be diagnosed appropriately early and treated successfully before the procedure, because bulimia nervosa does not regress spontaneously. When untreated, it may last for years, reducing the efficacy of a surgical treatment of obesity, or even lead to complications that are health- and life-threatening for patients.

XXL-TYPE PERSONALITY. Personality traits promoting excess body weight

THE AIM OF THE STUDY

The study aimed to determine whether persons suffering from obesity may be characterised by specific personality traits which promote the development of excess body weight. Additionally, the aim involved finding whether persons suffering from morbid obesity differed from healthy individuals and somatic patients as regards selected personality traits.

MATERIAL AND METHODS

The study enrolled 34 patients with the diagnosis of morbid obesity in the process of qualification for surgical treatment of obesity. The patients' BMI ranged from 35 to 54 kg/m2. Study participants completed NEO-FFI personality inventory (Costa, McCare; 1998) and the authors' questionnaire designed to collect demographic data and anthropometric measurements. R esults: The study showed that patients with morbid obesity significantly differed from healthy individuals and somatic patients as regards the analysed measurements of the Big Five. C onclusions: The traits which were significantly distinctive in morbidly obese patients included lowered conscientiousness and increased neuroticism. The results indicate that the above pattern of personality traits may promote the development of excessive body weight.

Postoperative pain relief in general surgery – recommendations of the Association of Polish Surgeons, Polish Society of Anaesthesiology and Intensive Therapy, Polish Association for the Study of Pain and Polish Association of Regional Anaesthesia and Pain Treatment

It is estimated that there are over 310 million surgeries performed in the world every year. Appropriate analgesic management in the perioperative period constitutes a fundamental right of every patient, significantly reducing the number of postoperative complications and the time and costs of hospitalization, particularly in the high-risk group of patients (ASA III-V) subject to extensive surgical procedures and hospitalized in intensive care units. Despite such significant arguments speaking for the conduct of effective analgesia in the perioperative period, nearly 79% of patients operated in hospitalization settings and 71% of patients operated in outpatient settings (so-called first day surgery) experienced postoperative pain of moderate, strong or extreme intensity. Hence, effective relief of postoperative pain should constitute one of the priorities of integrated, modern perioperative management, the components of which apart from adequate analgesia involve early nutrition through the alimentary canal, early patient activation and active physiotherapy. In the currently published “Guidelines”, a team of authors has updated the previous “Recommendations” primarily in terms of methods for optimizing postoperative pain relief and new techniques and drugs introduced for postoperative pain therapy in recent years. The algorithms of postoperative pain management in different treatment categories were also updated.

Impact of age on postoperative outcomes in bariatric surgery

BACKGROUND

Age is often related to the increase of perioperative complications and reoperation rates. The authors aimed to determine the influence of age on outcomes of most commonly performed bariatric procedures.

METHODS

The retrospective study included patients qualified for primary Laparoscopic Sleeve Gastrectomy (LSG) or Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) in two academic hospitals. Patients were divided into two groups: ≥50 (21.2-26.9%) and <50 (57.6-73.1%) years old. Endpoints assessed the influence of patients' age on the perioperative and the one-year postoperative period.

RESULTS

Operative time was longer in the ≥50-year-old group, but only for LRYGB. There were no differences in the intraoperative adverse events, postoperative morbidity, reoperation and readmission rates between the groups. The risk of port site hernia was increased (OR: 4.23, CI: 1.49-12.06) in the ≥50-year-old group. The mean % of total weight loss 12 months after the bariatric procedure was comparable, but % of excess weight loss and % of excess body mass index loss were lower in the ≥50-year-old group (p = .033 and .032).

CONCLUSIONS

Bariatric surgery is safe and feasible in patients over 50 years old. The weight loss effect can be worse among patients over 50 years old; nevertheless, the treatment should be considered as effective.

Recommendations for the standards of equipping of the Bariatric and Metabolic Surgery Center

INTRODUCTION

The prevalence of obesity in Poland and worldwide is constantly rising. High effectiveness of bariatric surgery has been proven in literature. It is recommended that bariatric procedures should be done by highly qualified surgeons with the appropriate, up-to-date medical equipment.

AIM

The purpose of the study is to establish Polish recommendations and standards for the use of medical equipment for bariatric surgery centers.

MATERIALS AND METHODS

The review of the present recommendations of the worldwide organizations and societies (including EAES, IFSO, SAGES) and guidelines was made. On the basis of current literature and authors&apos;s clinical experience we proposed standardized protocol for bariatric surgical equipment.

CONCLUSIONS

Relevant equipping of bariatric surgery centers and implementation of standardized perioperative and surgery protocols will result in significant improvements in bariatric treatment. This will ensure patients safety, a shorter length of hospital stay and considerably reduce the risk of morbidity. Moreover, it will contribute to the efficacy of the bariatric and metabolic surgery procedures, in accordance with the highest globally accepted standards.

Long-Term Outcomes of Laparoscopic Sleeve Gastrectomy-a Single-Center, Retrospective Study

Introduction

Sleeve gastrectomy (LSG) is one of the most popular bariatric procedures. We present our long-term results regarding weight loss, comorbidities, and gastric reflux disease.

Material and Methods

We identified patients who underwent LSG in our institution between 2006 and 2009. We revised the data, and the patients with outdated contact details were tracked with the national health insurance database and social media (facebook). Each of the identified patients was asked to complete an online or telephone survey covering, among others, their weight and comorbidities. On that basis, we calculated the percent total weight loss (%TWL) and percent excess weight loss (%EWL), along with changes in body mass index (ΔBMI). Satisfactory weight loss was set at >50% EWL (for BMI = 25 kg/m²). We evaluated type 2 diabetes (T2DM) and arterial hypertension (AHT) based on the pharmacological therapy. GERD presence was evaluated by the typical symptoms and/or proton pump inhibitor (PPI) therapy.

Results

One hundred twenty-seven patients underwent LSG between 2006 and 2009. One hundred twenty patients were qualified for this study. Follow-up data was available for 100 participants (47 female, 53 male). Median follow-up period reached 8.0 years (from 7.1 to 10.7). Median BMI upon qualification for LSG was 51.6 kg/m². Sixteen percent of patients required revisional surgery over the years (RS group), mainly because of insufficient weight loss (14 Roux-Y gastric bypass—LRYGB; one mini gastric bypass, one gastric banding). For the LSG (LSG group n = 84), the mean %EWL was 51.1% (±22.3), median %TWL was 23.5% (IQR 17.7–33.3%), and median ΔBMI was 12.1 kg/m² (IQR 8.2–17.2). Fifty percent (n = 42) of patients achieved the satisfactory %EWL of 50%. For RS group, the mean %EWL was 57.8% (±18.2%) and median %TWL reached 33% (IQR 27.7–37.9%). Sixty-two percent (n = 10) achieved the satisfactory weight loss. Fifty-nine percent of patients reported improvement in AHT therapy, 58% in T2DM. After LSG, 60% (n = 60) of patients reported recurring GERD symptoms and 44% were treated with proton pomp inhibitors (PPI). In 93% of these cases, GERD has developed de novo.

Conclusions

Isolated LSG provides fairly good effects in a long-term follow-up with mean %EWL at 51.1%. Sixteen percent of patients require additional surgery due to insufficient weight loss. More than half of the subjects observe improvement in AHT and T2DM. Over half of the patients complain of GERD symptoms, which in most of the cases is a de novo complaint.

Cigarette smoking and its impact on weight loss after bariatric surgery: A single center, retrospective study

BACKGROUND

Smoking cessation is often associated with weight gain. This study was conducted to verify whether it affects outcomes of bariatric surgery.

OBJECTIVES

To present cigarette consumption among patients after bariatric surgery in a long-term follow-up and to evaluate whether smoking cessation impacts weight loss.

SETTING

High-volume bariatric center, Military Hospital, Poland.

METHODS

We collected data of patients who underwent bariatric surgery between 2003 and 2009. The data included sex, age, weight, body mass index, and smoking habits. An online survey regarding current weight, co-morbidities, and smoking was distributed. Percentage excess weight loss was calculated with an ideal weight for body mass index of 25 kg/m².

RESULTS

One hundred seven patients had laparoscopic adjustable gastric banding between 2003 and 2006; 47 were included in the study. The mean follow-up time was 11.2 (±1.2). Of patients, 51% (n = 24) were smokers before surgery. In the follow-up 43% (n = 20) were smokers, of whom 4 patients began smoking after surgery. Twenty-seven patients were nonsmokers, 8 of whom quit over the years (33% of previous smokers). One hundred twenty-seven underwent laparoscopic sleeve gastrectomy between 2006 and 2009; 84 were included in the study. Our median follow-up was 8.0 years. Thirty-two patients never smoked; 52 were smoking before surgery, yet 24 successfully quit. In both groups there were no statistically significant differences in percentage excess weight loss between smokers and nonsmokers, or between those who quit and did not.

CONCLUSIONS

In the long-term follow-up after laparoscopic adjustable gastric banding, 33% of smokers quit and 17% previously nonsmoking began smoking. After laparoscopic sleeve gastrectomy, 46% of previously smoking patients successfully quit. Smoking status was not significantly associated with weight loss.

Does previous abdominal surgery affect the course and outcomes of laparoscopic bariatric surgery?

BACKGROUND

Global experiences in general surgery suggest that previous abdominal surgery may negatively influence different aspects of perioperative care. As the incidence of bariatric procedures has recently increased, it is essential to assess such correlations in bariatric surgery.

OBJECTIVES

To assess whether previous abdominal surgery influences the course and outcomes of laparoscopic bariatric surgery.

SETTING

Seven referral bariatric centers in Poland.

METHODS

We conducted a retrospective analysis of 2413 patients; 1706 patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) matched the inclusion criteria. Patients with no history of abdominal surgery were included as group 1, while those who had undergone at least 1 abdominal surgery were included as group 2.

RESULTS

Group 2 had a significantly prolonged median operation time for RYGB (P = .012), and the longest operation time was observed in patients who had previously undergone surgeries in both the upper and lower abdomen (P = .002). Such a correlation was not found in SG cases (P = .396). Groups 1 and 2 had similar rates of intraoperative adverse events and postoperative complications (P = .562 and P = .466, respectively). Group 2 had a longer median duration of hospitalization than group 1 (P = .034), while the readmission rate was similar between groups (P = .079). There was no significant difference between groups regarding the influence of the long-term effects of bariatric treatment on weight loss (percentage of follow-up was 55%).

CONCLUSIONS

Previous abdominal surgery prolongs the operative time of RYGB and the duration of postoperative hospitalization, but does not affect the long-term outcomes of bariatric treatment.

Age is not associated with increased surgical complications in patients after laparoscopic sleeve gastrectomy

INTRODUCTION

Age is considered as a risk factor in bariatric surgery. The observation was made on the basis of results from studies where patients underwent different type of surgery, but laparoscopic sleeve gastrectomy (LSG) was not among them. It is necessary to reevaluate the association of age with adverse events in the group of patients after LSG.

AIM

To investigate the association of age with surgery-related adverse events in patients after LSG.

MATERIAL AND METHODS

Retrospective analysis of medical data was performed. The study involved 345 patients who underwent LSG in our institution between January 2013 and December 2014. The patients were subdivided by age into four groups according to quartiles. In 30-day follow-up adverse events were evaluated. We considered the presence of the following events as the endpoint of our study: death, medical events and surgical events.

RESULTS

In general, we observed adverse events in 36 (10.4%) patients. The mortality rate in our study was 0.59%. Nineteen events were surgical and 18 medical. In 1 patient a surgical event was associated with a medical event. Bleeding was the most common surgical event and was observed in 17 (4.9%) cases. Age was not associated with surgical events (OR = 1.032, 95% CI: 0.991-1.075, p = 0.33) or medical events (OR = 0.997, 95% CI: 0.956-1.039, p = 0.89).

CONCLUSIONS

The LSG is a safe bariatric procedure with low mortality. Bleeding is the most frequent surgical complication. Our findings suggest that age is not associated with increased risk of surgical or medical adverse events after LSG.

Life with a Gastric Band. Long-Term Outcomes of Laparoscopic Adjustable Gastric Banding-a Retrospective Study

Background

Laparoscopic adjustable gastric banding (LAGB) is the third most popular bariatric procedure worldwide. Various authors present ambivalent long-term follow up results.

Methods

We revised records of the patients who underwent LAGB between 2003 and 2006 along with history of additional check-ins. Patients with outdated details were tracked with the national health insurance database and social media (Facebook). An online survey was sent. The patients who did not have their band removed were included in this study. We calculated the percent total weight loss (%TWL) and percent excess weight loss (%EWL), along with changes in body mass index (ΔBMI). Satisfactory weight loss was set at >50% EWL (for BMI = 25 kg/m²). Since eight patients gained weight, we decided to include negative values of %TWL, %EWL, and ΔBMI.

Results

One hundred seven patients underwent LAGB from 2003 to 2006. The mean follow-up time was 11.2 (±1.2) years. Eleven percent of patients were lost to follow up (n = 12). There was one perioperative death. Fifty-four of the patients (n = 57) had their band removed. Thirty-seven patients still have the band (39%) and were included in the study. The mean %EWL was 27% (−56–112%) and %TWL was 11% (−19–53%). Twelve patients achieved %EWL > 50% (32%). Thiry-two patients still suffer from obesity, with BMI over 30 kg/m². Eight patients (22%) gained additional weight. Patients with %EWL > 50% suffered less from gastroesophageal reflux disease symptoms than those with EWL < 50% (p < 0.05).

Conclusions

Out of 107 cases, only 11.2% of patients with gastric band (n = 12) achieved satisfactory %EWL. Twenty–two percent of patients regained their weight or even exceeded it. Overall results suggest that LAGB is not an effective bariatric procedure in long term observation.

Quality of Life and Bariatric Surgery: Cross-Sectional Study and Analysis of Factors Influencing Outcome

Purpose

The aims of our study were to compare quality of life (QOL) in obese patients after bariatric surgery with that in controls seeking surgery and to investigate which factors are associated with QOL in the Moorehead–Ardelt Quality of Life Questionnaire II (MA II).

Materials and Methods

This was a cross-sectional study. The operated group consisted of patients after laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. The MA II was administered by e-mail to 305 patients 12–18 months after surgery. The control groups consisted of 101 obese patients. We compared the QOL scores and considered good and very good outcomes to be satisfactory. Multiple logistic regression and correlation analysis was performed to identify factors associated with QOL.

Results

In the operated group, the total MA II score was 1.70 ± 0.76, which was higher than 0.59 ± 1.17 in the control group. The score adjusted for the type of surgery was comparable. The prevalence of satisfactory QOL outcomes was similar in both post-operative subgroups and was still higher than in the control group. We identified four factors associated with higher QOL in obese patients. Weight loss was not correlated with total score in MAII.

Conclusions

This study demonstrates that patients after bariatric surgery have a higher score in MA II, which reflects better QOL. The scoring adjusted by type of operation is comparable. QOL among obese patients is dependent on age, gender, history of bariatric surgery, and partnered status. Body mass reduction was not associated with outcome in MAII.

Prediction Model for Hemorrhagic Complications after Laparoscopic Sleeve Gastrectomy: Development of SLEEVE BLEED Calculator

Introduction

Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures. Hemorrhagic complications (HC) after surgery are common and require surgical revision. Accurate estimation of the risk of postoperative HC can improve surgical decision-making process and minimize the risk of reoperation. The aim of the present study was to develop a predictive model for HC after LSG.

Material and Methods

The retrospective analysis of 522 patients after primary LSG was performed. Patients underwent surgery from January 2013 to February 2015. The primary outcome was defined as a surgical revision due to hemorrhagic complications. Multiple regression analysis was performed.

Results

The rate of hemorrhagic complications was 4 %. The mean age of patients was 41.0 (±11.6) years and mean BMI was 47.3 (±7.3) kg/m². Of the 12 examined variables, four were associated with risk of HC. Protective factors for HC were no history of obstructive sleep apnea (odds ratio [OR] 0.22; 95 % CI 0.05–0.94) and no history of hypertension (OR 0.38; 95 % CI 0.14–1.05). The low level of expertise in bariatric surgery (OR 2.85; 95 % CI 1.08–7.53) and no staple line reinforcement (OR 3.34; 95 % CI 1.21–9.21) were associated with higher risk of HC.

Conclusions

The result revealed the association between hemorrhagic complications and the following factors: obstructive sleep apnea, hypertension, level of expertise in bariatric surgery, and reinforcement of the staple line. The risk assessment model for hemorrhagic complications after LSG can contribute to surgical decision-making process.

Case-Control Study of Postoperative Blood Pressure in Patients with Hemorrhagic Complications after Laparoscopic Sleeve Gastrectomy and Matched Controls

INTRODUCTION

Laparoscopic sleeve gastrectomy is associated with a moderate risk of hemorrhagic complications (HC). There is a debate regarding the relationship between HC and high blood pressure in postoperative period.

AIM

The aim is to clarify whether the postoperative blood pressure is an independent risk factor for hemorrhagic complications after laparoscopic sleeve gastrectomy.

METHODS

Medical records of 522 patients were reviewed. A case-control study of postoperative blood pressure was undertaken in patients with bleeding after LSG and matched controls. Patients who required surgical revision, due to the hemorrhagic complications within 72 hours, were identified as the cases. Controls were matched (1:1) with cases by age (±1 year), gender (female versus male), staple line reinforcement (running suture versus haemostatic clips) and surgeon's experience (>50 or <50 LSG procedures per year). 12-hour postoperative blood pressure was recorded.

RESULTS

17 patients after LSG with HC in postoperative period were matched with 17 controls. Patients who experienced hemorrhagic complications after LSG had non statistically significant decreased mean systolic blood pressure (mmHg) in 12 hours observation (130.7 ± 12.9 versus 139.1 ± 10.8); p = 0.15; mean difference - 11.6 (95% CI -29.5 - 6.1). Mean 12 hour diastolic pressure was also comparable. The detailed analysis of controls revealed a significantly higher systolic blood pressure measurements in 5th and 11th hour postoperatively, as well as higher diastolic blood pressure in 12th hour postoperatively. However, the differences were not clinically significant.

CONCLUSION

Compared with closely matched control subjects, patients with HC after LSG have decreased systolic blood pressure without clinical significance.

Present status of bariatric surgery in Poland

INTRODUCTION

The first survey of bariatric surgery in Poland was published in 2007. New trends are observed worldwide, and there is a current need to investigate the status of bariatric surgery in Polish institutions. This survey was initiated to gain an overview of Polish bariatric surgery during 2007-2014.

AIM

To analyze the number and types of bariatric procedures performed in Polish institutions in 2014 and to perform a trend analysis from 2007 to 2014.

MATERIAL AND METHODS

A questionnaire regarding the numbers and types of bariatric procedures performed between 2007 and 2014 was e-mailed to all members of the Bariatric Society (a branch of the Association of Polish Surgeons) and to 28 surgical departments. Trend analyses from 2007 to 2014 were performed.

RESULTS

Among the surgical departments, 16 (57%) responded. The results showed that 1499 bariatric procedures were performed in Poland in 2014, with 96.4% done laparoscopically. The highest number was from Masovian Voivodeship. The most commonly reported procedures were laparoscopic sleeve gastrectomy (LSG) (60.7%), followed by laparoscopic Roux-en-Y gastric bypass (19.2%), mini gastric bypass (11.1%), and adjustable gastric banding (7.6%). Most significant was the rise in prevalence of LSG from 8.0% to 60.4% of the total bariatric procedures from 2007 to 2014.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is currently the most frequently performed bariatric procedure in Poland. The accuracy of the national survey of procedures would be enhanced if we could create a national registry.

[Retroperitoneal perforation of duodenum - surgical approach]

Retroperitoneal perforation of the duodenum, caused by abdominal trauma, endoscopic examination or diverticulitis, is a serious clinical problem, because of it's lack of specific symptoms. Surgical treatment is often performed in sepsis. That is why the knowledge of adequate techniques is crucial for surgeons. We would like to present our model of surgical approach, based on several trauma center's cases. Among the methods and techniques presented we emphasize the duodenal by-pass with bile duct drainage. Post-op cases of gastrojejunal anastomosis' bleeding prompt to implement a selective vagotomy, which however requires further studies.

Large inflammatory fibroid polyp of cardia managed laparoscopically - a case report and review of the literature

Inflammatory fibroid polyp or Vanek's tumor of the gastrointestinal tract is a rare, benign neoplasm. The lesion may occur at any age but is commonest in the sixth and seventh decades and is more often found in women. It is mostly situated in the stomach, especially in the antrum. Symptoms depend on the location and the size of the lesion. We present a case of a 67-year-old woman with a large inflammatory polyp of the cardia with a diameter of 10 cm × 5.5 cm × 7.5 cm imitating gastrointestinal stromal tumor (GIST). The patient complained of abdominal pain, nausea and mild anemia. We performed laparoscopic topical excision of the tumor. The postoperative course was uneventful. The 6-month follow-up did not reveal recurrence. The clinical image of a large Vanek's tumor can imitate symptoms of gastric cancer or GIST. Topical laparoscopic excision with a 1-2 cm healthy wall margin is a sufficient and adequate way of treatment.

[Usefulness of the multislices computed tomography in post-operative anatomy assessment in patients after bariatric surgery]

Obesity is a systemic disease, which, together with complications and comorbidities is a major health problem of a large percentage of the world population. Because of the failure of behavioral and pharmacological treatment the new branch of surgery has been developed - the so-called bariatric surgery, dealing with operative treatment of obesity. Rapid increase of performed bariatric procedures requires the ability to interpret correctly the multislice CT imaging studies of patients treated with this innovative procedures. This paper is a review of commonly used methods of surgical treatment of obesity and identifies the usefulness of multislice computed tomography (CT) imaging of postoperative abdominal and pelvic anatomy. Surgical techniques are divided into treatments for restrictive mechanism, malabsorptive mechanism and combined both mechanisms. Abdominal and pelvic CT imaging before and after intravenous contrast agent administration confirmed their clinical utility.

[Syndromic surveillance in circumstances of bioterrorism threat--the essence, application abilities and superiority over a traditional epidemiological surveillance]

This article provides a short review about trends of developing current syndromic surveillance systems. To improve methods of early detection of natural or bioterrorism-related outbreaks, it has to be established a new way of epidemiological thinking, which uses innovative real-time surveillance systems. Syndromic surveillance has been created for an early detection, to monitor the temporo-spatial spread of an outbreak, and to provide prompt data for immediate analysis and feedback to public health authorities. It supports timely decision making process for countermeasure procedures. Framework of syndromic surveillance system requires a proper electronic infrastructure to be build up. Optimal syndrome definitions and data sources for continuing specific diseases outbreak surveillance have not been determined so far. Systems of interest might enhance collaboration among clinical providers, primary care providers, emergency services, information-systems professionals and public health agencies. However economic scope of this undertakings effectively limits ability to implement it in Polish public health service right now. Besides, syndromic surveillance cannot replace traditional public health surveillance with a post-factum epidemiological investigation and laboratory analysis. It can be a useful supplement.

[Evolution of views on surgical treatment of gastroesophageal reflux disease and hiatal hernia]

This year it has been 90 years since the first hiatal hernia repair was performed (Soresi, 1919). Nowadays surgeons' approach to operational treatment has changed as a result of development of more precise imaging techniques, better understanding of physiology and pathology of gastroesophageal reflux disease (GERD), invention of effective medicines and alternative endoscopic procedures. Complications and discomfort in patients during a follow-up resulted in evolution of surgical methods. Close co-operation between surgeons and gastroenterologists and interchange of experiences among surgeons have allowed establishing general algorithm for therapeutic and preoperational management. It seems crucial for further defining of surgical management of hiatal hernia and reflux disease to have at least basic knowledge on previous medical views on GERD. Another reason for taking the subject is epidemiology, oncological prophylaxis and quality of life improvement in patients with reflux disease. It has been proven that the most effective way of operational treatment of GERD is creating with the liberated gastric fundus a full "floppy" wrap around the lower esophagus. The procedure is completed with narrowing of esophageal hiatus. In cases of impaired esophageal motor activity the partial (180 degrees) posterior fundoplication is widely used. In hiatal hernias, particularly of type II or paraesophageal hernias, the diaphragmatic defect can be repaired with surrounding tissues or, when large, with a synthetic mesh.

[The outcomes of treatment of gastroesophageal reflux disease with laparoscopic "floppy" fundoplication]

Gastroesophageal reflux disease (GERD) has been a serious health and social problem. Population based survey revealed that around 40 per cent of the whole population reported monthly GERD related symptoms. When not treated properly GERD can lead to severe complications such as Barrett's oesophagus (BE) and adenocarcinoma as a consequence. Various methods can be useful in diagnosis of GERD but only gastroscopy is a widespread investigation that enables to establish the diagnosis of reflux disease. The symptoms of reflux disease can be effectively treated by drugs, surgical procedures remain the way of curing the cause of gastroesophageal reflux. Nowadays the laparoscopic fundoplication is a standard in operative treatment of the ailment.

AIM OF STUDY

was to evaluate of GERD treatment with laparoscopic "floppy" Nissen fundoplication (LFN).

MATERIAL AND METHODS

A group of 41 patients who underwent LNF were recruited for the study. All qualified patients underwent pre and post-surgical upper GI endoscopy and were requested to answer the questions in a GERD-related quality of life questionnaire. The main group of patients was divided into two subgroups--those with concomitant hiatal hernia and those without hernia. The outcomes of treatment were then compared between the subgroups.

RESULTS

After the procedure the endoscopic improvement of reflux oesophagitis and better symptoms self-assessment were found.

CONCLUSIONS

Laparoscopic "floppy" Nissen fundoplication is an effective method of treatment of erosive oesophagitis and its symptoms.

[New trends in bariatric surgery]

The surgical treatment of obesity reaches the 50th of last century. The first operations were based on significant shortening of digestive tract and were associated with many metabolic disturbances. The growing epidemic of obesity was the most decisive factor for the development of bariatric surgery. Because of its high efficacy (80%) comparing to the conservative treatment (5%), bariatric surgery today is the only effective therapy for morbid obesity. Surgical procedures can be categorized as restrictive, restrictive-malabsorptive, malabsorptive and others. The restrictive operations limit gastric volume. There are Vertical Banded Gastroplasty (VBG), Adjustable Gastric Banding (AGB) and Sleeve Resections (SR). The restrictive-malabsorptive are based on the creation of small gastric pouch or the resection of 4/5 of stomach and the shortening of common digestive tract. There are Gastric bypass (GB), and Biliopancreatic divertion with duodenal switch (BPD-DS). The malabsorptive procedure (Biliopancreatic divertion--BPD) are based on resection of 2/3 of stomach and significant shortening of digestive tract. The appearance of new bariatric operation such as SR changed the pattern of treating obesity with BMI >50 kg/m2. The two or three stage treatment of obesity minimizes the perioperative risk for patients. Although the great development of bariatric surgery there is no golden standard. The choice of procedure should be done by surgeon and patient together.

[Therapeutic and diagnostic problems in a patient with a pelvic tumour--case report]

Colorectal cancer has become the commonest form of cancer in gastrointestinal (GI) tract and nowadays it is the second cause of death among all malignant tumours. Bladder cancer is the fourth commonest tumour in males and eighth in females. In the article we present the case of 72-year-old patient with pelvic tumour and accompanied diagnostic and therapeutic problems. Despite repeated colon and bladder biopsies no malignancy was found. The results of imaging investigations suggested a bladder-derived tumour (from a bladder diverticulum or persisting urachus). An inflammatory tumour was also taken into consideration. The diagnosis confirmed in histological examination was adenocarcinoma of the colon. The article presents successive stages of diagnosis and therapy.

[Current methods of ventral hernias repair]

Hernioplasty is the most common procedure performed on surgical wards. The golden standard among the different techniques of hernia repair is the usage of mesh. It resulted in the reduction of recurrences below 1% of primary repairs. Usage of the artificial material results in less numbers of recurrences which is 1% less than primary repairs. The aim of this article was to review contemporary opinions on repair operations of an abdominal hernia. Appropriate documentation and publications were reviewed in this area. We presented the usage of new techniques in ventral hernioplasty including laparoscopic approach and the intraperitoneal usage of mesh. The presentation was based on references and our experience. Conclusions regarding the lack of treatment standards and superiority of usage of the artificial materials method were formulated accordingly.

[Selected lifestyle characteristic of patients with extreme obesity qualified for bariatric surgery]

The aim of the study was the analysis of chosen nutritional habits and physical activity among patients qualified for bariatric surgery. The research was conducted by questionnaire method. The results of the study show that number and regularity of meals was improper. Everybody snack, eg. sweets. About 50% of researched read information on the food packages, but only few participants paid attention to the nutritional and energy value of food products. TV and radio were the main source of nutritional information. Nutritional behaviors men and women were different. The level of physical activity was low.

[Comparison of the results of surgical treatment of patients suffering from gastroesophageal reflux disease with unanatomical and anatomical dysfunction of gastroesophageal junction]

The evolution of surgery of no neoplastic diseases of the gastroesophageal junction, particularly gastroesophageal reflux disease (GERD), is an unquestionable factor for further analysis of indications for treatment and treatment results. Full-symptomatic GERD with coexisting sliding hiatal hernia is an indication for surgical treatment for a long time. The question is when to operate functional disorders of the esophagus and lower esophageal sphincter (LES) and what the results of the treatment are. Aim of study was to analyze results of surgical treatment of patients with GERD on the background of functional disorders and patients with sliding and mixed hiatal hernia.

MATERIAL AND METHODS

This study retrospectively analyzed the data of 49 patients operated in Department of General, Oncological and Thoracic Surgery. Patients were divided into two groups. First group: patients with symptomatic GERD with confirmed 24 hour pH monitoring night-time and after-meal acid refluxes--23 subjects. Second group: patients with symptomatic GERD with type I and III hiatal hernia proven by gastroscopy, radiological tests and intraoperative examinations--26 subjects. There was no sign of decreased esophageal propulsive function among examined patients. For surgical intervention from the first group were qualified patients after ineffective conservative management. All patients underwent Nissen procedure--laparoscopy, hernioplasty and floppy fundoplication, and agreed on follow-up evaluation after 3, and some after 6 and 12 months which included case history, gastroscopy and 24 hour pH monitoring.

RESULTS

Operative management resulted in withdrawal of suffered subjective symptoms and remission of lesions in lower part of esophagus. 10% of the patients had LES motor activity dysfunction not qualified for surgical consultation. There was no case of recurrence of hiatal hernia.

CONCLUSIONS

Patients suffering from LES functional disorders and type I and III hiatal hernia can be effectively treated with surgical management.

[Indications and contraindications for surgical treatment of morbid obesity--the choice of operative method]

Surgery for morbid obesity should be considered in case of failure of conservative treatment (diet, physical activity, psychotherapy, supportive medications). It is strongly recommended also for patients with significant concomitant diseases (e.g. cardiovascular, pulmonary etc) difficult to manage with traditional therapy. Patients' selection for surgery seems to be essential issue. Typical indications for surgical procedure include: BMI > 40 or BMI > 35 in patients with at least two obesity-related diseases, ineffective conservative treatment. Main contraindications are GI tract diseases (esophagitis, peptic ulcer), severe cardiovascular insufficiency, alcohol or drug abuse and mental disorders. There are two types of operative procedures currently performed restrictive and malabsorptive. The first group consists of following operations: 1) Silicon Ring Vertical Gastroplasty (SRVG), 2) Vertical Banded Gastroplasty (VBG), 3) Adjustable Silicon Gastric Banding (ASGB), 4) Non-Adjustable Gastric Banding (NGB). The latter group comprises: 1) Roux-Y Gastric By-Pass (RYGB) and 2) Bilipancreatic diversion. The paper describes complications, advantages and disadvantages for both groups of bariatric procedures and points out factors that should be considered in patients' selection for various types of operation.

[Contemporary methods of the surgical treatment of nonspecific inflammatory bowel diseases]

Significant number of patients suffering from Crohn's disease (CD) and ulcerative colitis (UC) require surgical treatment on various stages of disease. Operative treatment of CD is usually indicated due to complications or ineffective medical treatment, but recurrence of disease and need for reoperation is common. Indications for surgical management in UC include complications (e.g. hemorrhage, perforation, toxic colitis) and prevention of late complications or neoplastic transformation. The role of surgery in the management of inflammatory bowel diseases has been confirmed thanks to recent development in operative techniques, advances in pathophysiology and introduction of laparoscopic methods, which result in improved life quality and better postoperative outcome. The paper presents indications for surgical treatment and practical aspects of operative techniques.

[The impact of postoperative weight loss on concomitant obesity-related diseases]

Obesity-related diseases, especially diabetes mellitus and hypertension, have huge impact on mortality in obese patients. The aim of the study was the assessment of relationship between postoperative weight loss and further management of concomitant, obesity related diseases (hypertension and diabetes). The group of 106 patients who underwent restrictive procedures for morbid obesity at our department was retrospectively analyzed. Data were collected on follow-up visits according to designed questionnaires. Nine of thirty-two diabetic patients (28.13%) did not require any treatment after surgery, while in fourteen cases (43.75%) previous dosages of insulin were modified (reduced). Nine diabetic patients (28.13%) required the same treatment as before. Bariatric surgery had significant impact on patients with arterial hypertension. Antihypertensive drugs dose was reduced in 43.9% of patients, whereas 31.5% became normotensive in postoperative course (statistically significant). None of the operations appeared to be superior to others in terms of diabetes mellitus and hypertension control in postoperative course. Improvement in concomitant diseases management was markedly better for patients with lower preoperative BMI. Restrictive operations had positive impact on concomitant obesity-related diseases and cured about 30% of patients with preoperative diagnosis of diabetes or arterial hypertension.

[Surgical treatment of gastroesophageal reflux disease]

Advances of minimally invasive surgery caused return to operative treatment of gastroesophageal reflux disease (GERD). Authors present advantages and faults of laparoscopic treatment of gastroesophageal reflux disease (in literature and own experience).

[Laparoscopic colorectal surgery--own experience]

The advent of laparoscopic colorectal surgery evoked discussion on its advantages and limitations. Although application of laparoscopy in the management of benign colorectal diseases has been widely accepted, its use for treatment of malignancies is still controversial. Many reports suggest that laparoscopic operations provide similar oncological radicality as open procedures, with less operative trauma, shorter hospital stay and low complication rate. In the hands of well-trained surgeon laparoscopic colorectal surgery seems to be attractive operative modality. Authors present own experience with laparoscopic colorectal surgery.