摘要:

ObjectiveTo evaluate early and late morbidity of laparoscopic adjustable gastric banding for morbid obesity and to assess the efficacy of this procedure by analyzing its results.Summary Background DataLaparoscopic adjustable gastric banding is considered the least invasive surgical option for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. It is potentially reversible and safe; major morbidity is low and there is no mortality.MethodsBetween April 1997 and June 2001, 500 patients underwent laparoscopic surgery for morbid obesity with application of an adjustable gastric band. There were 438 women and 62 men (sex ratio = 0.14) with a mean age of 40.4 years. Preoperative mean body weight was 120.7 kg and mean body mass index (BMI) was 44.3 kg. m−2.ResultsMean operative time was 105 minutes, 84 minutes during the last 300 operations. Mean hospital stay was 4.5 days. There were no deaths. There were 12 conversions (2.4%), 2 during the last 300 operations. Fifty-two patients (10.4%) had complications requiring an abdominal reoperation. Forty-nine underwent a reoperation for minor complications: slippage (n = 43, incisional hernias (n = 3), and reconnection of the catheter (n = 3). Three patients underwent a reoperation for major complications: gastroesophageal perforation (n = 2) and gastric necrosis (n = 1). Seven patients had pulmonary complications and 36 patients experienced minor problems related to the access port. At 1-, 2-, and 3-year follow-up, mean BMI decreased from 44.3 kg. m−2to 34.2, 32.8, and 31.9, respectively, and mean excess weight loss reached 42.8%, 52%, and 54.8%.ConclusionsLaparoscopic adjustable gastric banding is a beneficial operation in terms of excessive weight loss, with an acceptably low complication rate. It can noticeably improve the quality of life in obese patients. Half of the excess body weight can be effortlessly lost within 2 years.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the use of a low-pressure gastric band in the treatment of severe obesity in a prospective study.Summary Background DataGastric banding for severe obesity has been associated with erosion and perforation of the stomach. The Swedish adjustable gastric band (SAGB) has been proposed as a low-pressure device.MethodsFrom January 1998 to October 2001, 625 patients underwent laparoscopic SAGB. Median age was 36 years, and 80.4% of patients were female. Median preoperative body mass index (BMI) was 40. Previous upper abdominal surgery was reported in 36 (6%) patients. A five-trocar technique was used without a calibration balloon.ResultsMedian follow-up was 19.5 months. All patients were treated laparoscopically with a median operating time of 80 minutes. Conversion was necessary in two patients (0.3%): one trocar injury of the mesentery and one esophageal perforation. Median hospital stay was 3 days; there were no 30-day deaths. Early morbidity was present in 27 patients (4.3%). Late band reoperation was necessary in 49 patients (7.8%). Indications for reoperation were band slippage or pouch dilation, acute total dysphagia, and band leakage or malfunction. Median excess weight loss was 45.8%, 49.9%, and 47.4% after 1, 2, and 3 years, respectively, with a measurable beneficial effect on arterial hypertension, sleep apnea syndrome, and diabetes control.ConclusionsSAGB is a safe and effective new method in the management of severe obesity. Long-term follow-up (>3 years) is necessary to confirm its effectiveness and safety.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo review the first clinical cases of composite tissue allotransplantation (CTA) for reconstructive surgery and to discuss the outcome of and indications for these procedures in the context of chronic immunosuppression.Summary Background DataThe first human hand transplant was performed in 1998. This procedure, as well as other composite tissue transplants, offers the potential for correcting untreatable large tissue defects. However, concerns remain regarding obligatory chronic immunosuppression and long-term functional results.MethodsAll the CTAs performed in humans that have been published or documented were reviewed. The preexisting clinical conditions and surgical procedures and the immunosuppressive therapy are described. The functional results and the complications or side effects of the treatment are detailed.ResultsVascularized tendons (two cases), vascularized femoral diaphyses (three cases), knees (five cases), hands (four bilateral and seven unilateral cases), larynx (one case), and nonvascularized peripheral nerves (seven cases) have been transplanted in humans in the past decade. Rejection was prevented in most cases without difficulty. Early results are encouraging, particularly for hand and larynx transplants, but will need to be evaluated in the long term and in a larger number of patients.ConclusionsCTA holds great potential for reconstructive surgery but is at present restricted by the risks of chronic immunosuppression and uncertain long-term results.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the oncologic and cosmetic outcomes in women with breast carcinoma who were treated with breast-conserving therapy using oncoplastic techniques with concomitant symmetrization of the contralateral breast.Summary Background DataAlthough breast-conserving therapy is the standard form of treatment for invasive breast tumors up to 4 cm, in patients with large, ill-defined, or poorly situated tumors, cosmetic results can be poor and clear resection margins difficult to obtain. The integration of oncoplastic techniques with a concomitant contralateral symmetrization procedure is a novel surgical approach that allows wide excisions and prevents breast deformities.MethodsThis is a prospective study of 101 patients who were operated on for breast carcinoma between July 1985 and June 1999 at the Institut Curie. The procedure was proposed for patients in whom conservative treatment was possible on oncologic grounds but where a standard lumpectomy would have led to poor cosmesis. Standard institutional treatment protocols were followed. All patients received either pre- or postoperative radiotherapy. Seventeen patients received preoperative chemotherapy to downsize their tumors. Mean follow-up was 3.8 years. Results were analyzed statistically using Kaplan-Meier estimates.ResultsMean weight of excised material on the tumor side was 222 g. The actuarial 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmesis was favorable in 82% of cases. Preoperative radiotherapy resulted in worse cosmesis than when given postoperatively.ConclusionsThe use of oncoplastic techniques and concomitant symmetrization of the contralateral breast allows extensive resections for conservative treatment of breast carcinoma and results in favorable oncologic and esthetic outcomes. This approach might be useful in extending the indications for conservative therapy.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo investigate alterations in immune responses after transhiatal versus transthoracic esophageal resection and to evaluate the role of preoperative immune functions in predicting postoperative infectious complications.Summary Background DataImpaired immune defense is associated with a decreased resistance to infection. Patients undergoing esophageal resection via a transhiatal or transthoracic approach are prone to develop infectious complications. There are no randomized data on immune responses after two major surgical interventions.MethodsThe study group consisted of 20 patients who were randomly allocated to a limited transhiatal or extended transthoracic esophagectomy for cancer. Blood samples were taken before the operation and at regular intervals thereafter from day 1 to day 10. Monocyte and T-helper type 1 (Th1) and type 2 (Th2) lymphocyte functions were assessed in stimulated whole blood cultures.ResultsBoth surgical groups had severely depressed in vitro production of interleukin (IL)-12, IL-10, interferon-&ggr;, IL-2, IL-4, and IL-13 on postoperative day 1. Depression of Th2-type cytokine production was more profound after transthoracic than after transhiatal esophagectomy (IL-4,P= .005; IL-13,P= .007). Postoperative reduction in Th1-type cytokine production was similar between the two groups (interferon-&ggr;,P= .40; IL-2,P= .06). Irrespective of the surgical approach, patients who developed major infectious complications after surgery presented with a diminished T-cell cytokine production before the operation compared to those who had a relatively uneventful recovery (IL-4,P= .045; interferon-&ggr;,P= .064). In regression analysis, the occurrence of postoperative major infection was best predicted by increased duration of anesthesia (P< .0001) and low preoperative interferon-&ggr; production (P= .006).ConclusionsBoth transhiatal and transthoracic esophagectomy induced severely depressed monocyte and T-lymphocyte cytokine production. The extent of the surgical procedure had a differential immunosuppressive impact on Th2-type but not on Th1-type cell activity, indicating that the two Th pathways were downregulated through distinct mechanisms. Preoperative interferon-&ggr; determination would be useful to anticipate the occurrence of postoperative major infectious complications.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the effects of hyperdynamic endotoxemia on the motility of the small intestine.Summary Background DataMotility disorders of the gastrointestinal tract are a common complication of sepsis. It has been suggested that gram-negative endotoxin plays a role in the pathogenesis of the accompanying diarrhea frequently observed.MethodsPigs were infused withEscherichia colilipopolysaccharide for a 24-hour period. During this fasting period jejunal motility was measured using ambulatory manometry. One and 4 days after cessation of endotoxin, pigs were enterally fed, and again motility was recorded.ResultsHyperdynamic endotoxemia was achieved in this model. Manometric pressure recordings revealed that endotoxin infusion accelerated the migrating motor complex (MMC) migration along the jejunum. Also, a simultaneous increase in MMC cycling frequency was observed in the endotoxin-treated group. Elevated MMC migration velocity and cycling frequency were maintained the following day after endotoxin during feeding and returned to basal values 4 days after endotoxin.ConclusionsA small dose of continuously infused endotoxin significantly provokes jejunal motility disturbances that may contribute to diarrhea.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the outcome of artificial anal sphincter implantation for severe fecal incontinence in 37 consecutive patients operated on in a single institution from 1993 through 2001.Summary Background DataImplantation of an artificial anal sphincter is proposed in severe fecal incontinence when local treatment is unsuitable or has failed. The results of this technique have not been determined yet, and its place among the various operative procedures is still debated.MethodsArtificial anal sphincters were implanted in 37 patients from 1993 through 2001. All patients had complete fecal incontinence and had failed to respond to medical treatment. Median duration of incontinence was 16 years. The causes of incontinence were sphincter disruption (19 patients), hereditary malformations (2 patients), and neurologic disease (16 patients). Six patients had had previous surgery for fecal incontinence. Assessment was made by physical examination (anal continence, rectal emptying) and anorectal manometry.ResultsIn the first 12 patients, six devices had to be removed (50%); the cause of failure was found in all cases, and this allowed contraindications to be defined. Among the next 25 patients, 23 had an uncomplicated postoperative follow-up, and 5 developed seven complications: control pump change (n = 3), balloon migration (n = 1), and major rectal emptying difficulties in patients with obstructive internal rectal procidentia (n = 2). The artificial anal sphincter had to be removed definitively in three cases, representing the failure rate of this technique in the authors’ experience (12%); two other devices had to be removed temporarily and the patients are awaiting reimplantation. In this latter group of 25 patients, 80% have an activated sphincter: continence for liquid stool is normal in 78.9%, continence for gas in 63.1%. Seven patients have rectal emptying difficulties, minor in five and major in two. Manometric studies showed mean pressures of 110 and 37 cm H2O with closed and open sphincter, respectively, with a mean duration of artificial sphincter opening of 128 seconds.ConclusionsThe long-term functional outcome of artificial anal sphincter implantation for severe fecal incontinence is satisfactory; adequate sphincter function is recovered and the definitive removal rate is low. Good results are directly related to careful patient selection and appropriate surgical and perioperative management after a learning curve of the surgical team.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether temporary occlusion of the main pancreatic duct with human fibrin glue decreases the incidence of intra-abdominal complications after pancreatoduodenectomy (PD) or distal pancreatectomy (DP).Summary Background DataTo the authors’ knowledge, there are no randomized studies comparing outcomes after pancreatic resection with or without main pancreatic duct occlusion by injection of fibrin glue. Of three nonrandomized studies, two reported no fistulas after intracanal injection and ductal occlusion with fibrin glue after PD with immediate pancreatodigestive anastomosis, while another study reported no protective effect of glue injection.MethodsThis prospective, randomized, single-blinded, multicenter study, conducted between January 1995 and January 1999, included 182 consecutive patients undergoing PD followed by immediate pancreatic anastomosis or DP, whether for benign or malignant tumor or for chronic pancreatitis. One hundred two underwent pancreatic resection followed by ductal occlusion with fibrin glue (made slowly resorbable by the addition of aprotinin); 80 underwent resection without ductal occlusion. The main end point was the number of patients with one or more of the following intra-abdominal complications: pancreatic or other digestive tract fistula, intra-abdominal collections (infected or not), acute pancreatitis, or intra-abdominal or digestive tract hemorrhage. Severity factors included postoperative mortality, repeat operations, and length of hospital stay.ResultsThe two groups were similar in pre- and intraoperative characteristics except that there were significantly more patients in the ductal occlusion group who were receiving octreotide, who had reinforcement of their anastomosis by fibrin glue, and who had fibrotic pancreatic stumps. However, the rate of patients with one or more intra-abdominal complications, and notably with pancreatic fistula, did not differ significantly between the two groups. There was still no significant difference found after statistical adjustment for these patient characteristic discrepancies, confirming the inefficacy of fibrin glue. The rate of intra-abdominal complications was significantly higher in the presence of a normal, nonfibrotic pancreatic stump and main pancreatic duct diameter less than 3 mm, whereas reinforcement of the anastomosis with fibrin glue or use of octreotide did not influence outcome. In multivariate analysis, however, normal pancreatic parenchyma was the only independent risk factor for intra-abdominal complications. No significant differences were found in the severity of complications between the two groups.ConclusionsDuctal occlusion by intracanal injection of fibrin glue decreases neither the rate nor the severity of intra-abdominal complications after pancreatic resection.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that laparoscopic staging improves outcome in patients with peripancreatic carcinoma compared to standard radiology staging.Summary Background DataDiagnostic laparoscopy of peripancreatic malignancies has been reported to improve assessment of tumor stage and to prevent unnecessary exploratory laparotomies in 10% to 76% of patients.MethodsLaparoscopy and laparoscopic ultrasound were performed in 297 consecutive patients with peripancreatic carcinoma scheduled for surgery after radiologic staging. Patients with pathology-proven unresectable tumors were randomly allocated to either surgical or endoscopic palliation. All others underwent laparotomy.ResultsLaparoscopic staging detected biopsy-proven unresectable disease in 39 patients (13%). At laparotomy, unresectable disease was found in another 72 patients, leading to a detection rate for laparoscopic staging of 35%. In total, 145 of the 197 patients classified as having “possibly resectable” disease after laparoscopic staging underwent resection (74%). Average survival in the group of 14 patients with biopsy-proven unresectable tumors randomly allocated to endoscopic palliation was 116 days, with a mean hospital-free survival of 94 days. The corresponding figures were 192 days and 164 days in the 13 patients allocated to surgical palliation.ConclusionsBecause of the limited detection rate for unresectable metastatic disease and the likely absence of a large gain after switching from surgical to endoscopic palliation, laparoscopic staging should not be performed routinely in patients with peripancreatic carcinoma.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID