Amir Szold

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BackgroundAlthough laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.MethodsAn international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.ResultsLaparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient’s age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon’s preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.ConclusionDespite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery

BackgroundLaparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus.MethodsA search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected.ResultsThe results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure.ConclusionsLaparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.

Bariatric surgery in adolescence

BACKGROUND/PURPOSE Surgical treatment for morbid obesity is relatively contraindicated in patients less than 18 years of age. However, on some occasions, there is extreme obesity in this age group that does not respond to nonsurgical treatment. The aim of this study was to evaluate the surgical management of severe morbid obesity in adolescents. METHODS During a 4-year period, the authors assessed 11 adolescent patients with severe morbid obesity. All patients underwent extensive preoperative evaluation including thorough psychological evaluation together with their families. Laparoscopic adjustable gastric banding (LAGB) was performed in all patients. Patients underwent follow-up for a mean of 23 months. RESULTS The mean age of the 11 children in this study was 15.7 years (range, 11 to 17 years). Associated conditions included heart failure and pulmonary hypertension in one patient, amenorrhea in 2 patients, and gallstones in 1 patient. Mean preoperative body mass index (BMI) was 46.4 kg/m2 (range, 38 to 56.6). There were no operative complications. Over a mean follow-up period of 23 months (range, 6 to 36 months), the mean BMI dropped from 46.6 to 32.1 kg/m2 with marked improvement in medical conditions and general psychologic well being. No late complications developed in any patient. CONCLUSIONS Children are routinely excluded from bariatric surgery programs because of the difficulties involved in psychologically and cognitively preparing this population for surgery. However, extreme morbid obesity rarely responds to nonsurgical therapy for any extended period. This select population will benefit from bariatric surgery if an effort is made to properly prepare patients, together with their families, for the postoperative change in lifestyle and body image.

Laparoscopic adjustable silicone gastric banding for morbid obesity

Background: Laparoscopic adjustable silicone gastric banding (LASGB) was used as the initial bariatric procedure for more than 36 months. The efficacy and safety of LASGB were studied. Methods: Patients were followed up prospectively in a multidisciplinary center for the perioperative and long-term courses, and for complications. Results: Between November 1996 and May 1999, 715 patients underwent surgery. The mean age was 34.6 years (range, 16-72) years, and the mean body mass index (BMI) was 43.1 kg/m2 (range, 35-66 kg/m2). The mean operative time was 78 min (range, 36-165 min), and the postoperative hospitalization time was 1.2 days (range, 1-8 days). There were six intraoperative complications (0.8%), eight early postoperative complications (1.1%), and no deaths. For follow-up evaluation, 614 patients (86%) were available. Late complications included band slippage or pouch dilation in 53 patients (7.4%), band erosion in 3 patients, and port complications in 18 patients. In 57(7.9%) patients, 69 major reoperations were performed. In patients with a follow-up period longer than 24 months, the average BMI dropped from 43.3 kg/m2 (range, 35-66 kg/m2) to 32.1 kg/m2 (range, 21-45 kg/m2). Conclusion: Laparoscopic adjustable silicone gastric banding is safe, with a lower complication rate than any other bariatric procedure. Most reoperations can be performed laparoscopically with low morbidity and short hospitalizations. On the basis of intermediate-term follow-up evaluation, it is an effective procedure for weight-reducing purposes.

The clinical spectrum of band erosion following laparoscopic adjustable silicone gastric banding for morbid obesity

BACKGROUND Morbid obesity is effectively treated by restrictive surgery. A severe complication associated with gastric banding is gastric erosion. We review here our experience over a 5-year period. METHODS A total of 1496 patients underwent gastric banding. Eighty-five percent of patients were available for follow-up. When band erosion was diagnosed, laparoscopic removal was performed. RESULTS Band erosion was identified in 17 patients (1.13%). The time from primary operation to diagnosis of band erosion ranged from 3 weeks to 45 months (mean, 19 months). Clinical manifestations included weight gain in 2 (11.6%), band system leak in 1 (5.8%), chronic port-cutaneous fistula in 2 (11.6%), neglected peritonitis in 1 (5.8%), left subphrenic abscess in 2 (11.6%), but most commonly, protracted port-site infection that occurred in 7 patients (40.6%). CONCLUSIONS Patients were effectively treated by band removal and suturing of the stomach wall. We suggest that different pathologies contribute to the same complication depending upon the time of presentation. We recommend a high index of suspicion in order to diagnose this life-threatening complication.

Port Complications following Laparoscopic Adjustable Gastric Banding for Morbid Obesity

Background: Laparoscopic adjustable gastric banding (LAGB) has gained widespread acceptance. However, the technique has problems intrinsic to the material wear and tear around the port and connecting tubing that can lead to failure. Port complications are considered to be minor; however, few studies have analyzed them, and the optimal technique of port implantation and management has not been elucidated. Methods: All patients who suffered from complications involving the tubing or access-port were included in this study. Their complaints, imaging studies, operative reports and hospitalization files were retrospectively reviewed. Results: 1,272 of the patients were available for a mean follow-up period of 37 months. During this time, 91 patients (7.1%) experienced port complications that required 103 revisional operations. Of these patients, 62 had system leaks, 19 infectious problems, and 10 miscellaneous problems requiring operative correction. Overall port problems led to band removal in 6 patients, and replacement in 1 patient. Conclusion: Access-port complications after the Lap-Band® procedure are among the most common and annoying ones, and can render the device susceptible to failure. Careful surgical technique and routine use of radiologic guidance for band adjustments are the keys to avoiding complications.

Resolution of chronic medical conditions after laparoscopic adjustable silicone gastric banding for the treatment of morbid obesity in the elderly

BackgroundThe routine cutoff age of surgery for morbid obesity is 55 years. A minimally invasive surgical approach, however, may enable its safe use in older individuals.MethodsLaparoscopic adjustable silicon gastric banding (LASGB) was performed in 18 patients 60 years or older. The perioperative course, early and late complications, and long-term follow-up all were recorded.ResultsOf 398 patients who underwent LASBG until November 1998 (mean age, 38.1 years), 18 were 60 years or older (mean, 63.6 years). The mean body mass index (BMI) was 44.4 (range, 35–64.7). There were no intraoperative complications. However, four patients had late complications requiring reoperation. The mean operative time was 65 min; the mean hospital stay was 1.3 days; and the mean follow-up period was 21.9 months. The BMI dropped from 44.2 to 30.5, and all comorbid conditions improved markedly: Diabetes mellitus resolved in 71% of the patients, hypertension in 33%, and sleep apnea in 100%.ConclusionAccording to the findings from this study, LASGB is feasible, safe, and effective in the elderly, and most benefit from resolution or marked improvement of comorbid conditions.

Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period.

Objective:To assess the immediate (0–4 hours) postoperative pain level in patients after laparoscopy and laparotomy whose analgesic requirement in the Post-Anesthesia Care Unit (PACU) exceeds standard morphine therapy. Background data:Clinical observation has raised the suspicion that laparoscopic surgery may be associated with more intense immediate postoperative pain than expected. Methods:This prospective study assessed the 24-hour pain intensity and analgesia requirements in patients who underwent similar abdominal surgery via laparoscopy or laparotomy under standardized general anesthesia and whose pain in the PACU was resistant to 120 &mgr;g/kg intravenous morphine. Results:Of 145 sampled PACU patients, 67 were in pain (≥6 of 10 VAS) within a 30-minute postoperative period. They were then given up to 4 intravenous boluses of 15 &mgr;g/kg morphine + 250 &mgr;g/kg ketamine. The pain VAS of 36 laparotomy patients was 4.14 ± 2.14 (SD) and 1.39 ± 0.55 at 10 and 120 minutes, respectively, after 1.33 ± 0.59 doses of morphine + ketamine; the pain VAS of 31 laparoscopy patient was 6.06 ± 1.75 and 2.81 ± 1.14, respectively (P < 0.0005) following 2.0 ± 0.53 doses (P = 0.0005). Diclofenac 75 mg intramuscular usage was similar (P = 0.43) between the groups up to 9 hours after surgery but was higher in the laparotomy group by 24 hours (P = 0.01). Pain scores at 24 hours after surgery were lower for the laparoscopy patients (3.01 ± 0.87) compared with their laparotomy counterparts (4.45 ± 0.98, P < 0.001). Conclusions:Among patients after abdominal surgery with severe immediate (0–4 hours) postoperative pain, laparoscopic patients are a significant (46%) proportion, and their pain is more intense, requiring more analgesics than painful patients (54%) do after laparotomy. By 24 hours, the former are in less pain than the latter.

Laparoscopic Adjustable Gastric Banding Prior to Renal Transplantation

End-stage renal failure is most commonly caused by the obesity-related diseases, diabetes mellitus and essential hypertension, and is best treated with renal transplantation. Obesity may contribute to poor patient and graft survival, and is an exclusion criterion in some renal transplant programs. Diet and exercise programs have not proven to be effective for weight loss before transplantation, and bariatric surgery in any form has not been used in this setting before. We report three morbidly obese patients who underwent laparoscopic adjustable gastric banding to meet the criteria for renal transplantation and subsequently were successfully transplanted.

Laparoscopic repair of paraesophageal hernia with selective use of mesh.

&NA; The laparoscopic approach to PEH, in use for close to a decade, shows promising results. However, data on the long‐term follow‐up of patients who undergo this procedure are still lacking, and the use of mesh is debatable. We retrospectively investigated 33 patients who underwent this procedure over a 30‐month period. In 10 patients, the repair was performed using a mesh prosthesis. There was one (3%) intraoperative and four (12%) early postoperative complications, with one mortality (3%). The average postoperative stay was 3 days. During a 58‐month follow‐up period, 18% of the patients developed small, sliding recurrent hernias, with a higher rate in the primary repair group (18% vs. 10%). Surgical outcome was scored good‐to‐excellent on a questionnaire by 84.5% of the patients. Laparoscopic repair of PEH is feasible and safe. While small recurrences do occur, functional results remain good. The use of mesh should be tailored to the specific patient.