Antonio Formato

Heliosphere® bag in the treatment of severe obesity : Preliminary experience

Background: Various intragastric balloons have been used in obese patients for temporary weight loss. Recently, a new balloon, the Heliosphere® Bag, was proposed. In a preliminary study, we evaluated the safety and efficacy of this device. Methods: The Heliosphere® Bag was used in 10 patients, selected according to the guidelines for obesity surgery. The manufacturers instructions were followed in positioning the device. Heliosphere® Bag positioning was performed, after diagnostic endoscopy, under unconscious sedation. After placement, the balloon was slowly inflated with 840-960 cc of air, which gives the inflated final volume of 650-700 cc of air, as the air is compressed. On the first and second post-treatment day, intravenous saline (30-35 ml/kg/d) with omeprazole (20 mg/d), ondansetron (8 mg/d) and butylscopolamine bromide (20 mg t.i.d.) were given to all patients. All patients from day 3 after placement began liquid diet and were discharged home on day 4 on a 1000 kcal diet (carbohydrate 146 g, lipid 68 g, protein 1 g/kg ideal weight). After 6 months, the Heliosphere® Bag was removed. The patients were followed monthly, and complications and their treatment, post-placement symptoms, BMI and %EWL were recorded. Data were expressed as mean ± SD. Results: From Sept-Dec 2004, 10 patients (5M/5F) underwent Heliosphere® Bag placement, with age 35.2 ± 15.7 years (17-49), BMI 43.3 ± 8.1 kg/m2 (35-51.2), and weight 126.8 ± 23.7 kg (98.4-148). Heliosphere® Bag positioning was quite difficult in all patients due to low pliancy and large size of the bag, causing patient discomfort. System failure at time of Heliosphere® Bag positioning was observed in 5/10 patients (50%). At time of removal, the Heliosphere® Bag was not found in the stomach in one patient. In 3 other patients, the balloon was found partially deflated. At the time of balloon removal after 6 months, BMI was 37.4 ± 13.4 (28.9-42.1) and %EWL was 29.1 ± 20.1 (9.0-57.4). BMI loss was 5.2 ± 13.1 (1.9-11.2) and mean weight loss was 17.5 ± 16.2 kg (5-33). Conclusions: Although weight loss was satisfactory, this device cannot be considered an advance for the temporary treatment of morbid obesity. This balloon still has some instrumental and technical problems that need to be solved: high rate of system failure at positioning, high rate of spontaneous deflation, absence of a marker such as methylene blue, and large size with low pliability that cause significant patient discomfort.

Laparotomic vs Laparoscopic Lap-Band: 4-year Results with Early and Intermediate Complications

Background: Adjustable banding is safe, low invasive, and effective for losing weight. Methods: 69 patients underwent this procedure by laparotomy or laparoscopy. Results: Patients operated by laparotomy lost more weight than those operated by laparoscopy, but in 4 patients we were forced to re-operate in order to remove the band (3 pouch dilatations and 1 stomach slippage), and in 9 patients a ventral hernia appeared (5 patients repaired). In the laparoscopic cases there were 4 intra-operative gastric perforations, but all were repaired and the band placed at the same time (3 conversions to open), causing an increased post-operative hospital stay.There was a lower limb deep venous thromboembolism, which was followed by fatal pulmonary embolism (although the patient had been given heparin and had been treated with elastocompression and mobilization 2 hours after surgery). The band eroded in one patient. Weight losses in these morbidly obese patients were satisfactory at 2 years and maintained beyond 3 years. Conclusion: Laparoscopic adjustable banding is an efficient, generally safe procedure.

Solitary necrotic nodule of the liver misinterpreted as malignant lesion: considerations on two cases.

In our experience, we document 2 cases of a rare and non‐tumoral lesion of the liver misinterpreted as necrotic tumor: necrotic solitary nodule. In the first clinical case, ultrasound (US) showed a polylobated lesion (35 × 35 × 38 mm) at segment 8. Color‐doppler identified a compression of celiac axis (Dunbar syndrome). Arteriography revealed a subtotal stenosis of celiac tripod soon after the emergence of the left gastric artery. FNAB‐CT showed a highly cellulated tissue with a necrotic core surrounded by a fibersclerotic tissue. The patient underwent surgery: cholecystectomy and correction of Dunbar syndrome. US follow‐up showed a progressive reduction in diameter of the lesion (24 × 25 × 25 mm at 24 months), suggesting in this case the role of ischemic injury in the pathogenesis of the lesion.

Two Years of Practice in Adjustable Silicone Gastric Banding (LAP-BAND™): Evaluation of Variations of Body Mass Index, Percentage Ideal Body Weight and Percentage Excess Body Weight

Background: In the treatment of morbid obesity, surgery had been the only method of obtaining a good and enduring weight loss. Although the procedure of choice is still a matter of debate, among gastric restriction procedures LAP-BAND™ has become our first choice. Methods: We report the results from 62 morbidly obese patients operated in the period October 1994-December 1996. Their characteristics were: mean age 35.6 years, mean body weight 130.6 kg, mean height 162.3 cm, mean body mass index (BMI) 49.9 kg/m2, mean percentage ideal body weight (%IBW) 215.7 and mean excess weight (EW) 69.57 kg. Results: Twenty-four months after surgery we found a mean BMI of 39.3, a mean %IBW of 168.6 and a mean % EW loss of 88.5. We removed the band in two patients: one after 9 months because of stoma stenosis and pouch enlargement in a woman who had been lost at follow-up, and the other for gastric slippage occurring after 18 months due to incorrect fixation of the band. Conclusion: Our results led us to consider LAP-BAND™ as the surgical approach for severe obesity among those patients selected for gastric restriction; indeed, it was very safe as well as effective and was rarely followed by complications.

Serum In Vivo and In Vitro Activity of Single Dose of Ertapenem in Surgical Obese Patients for Prevention of SSIs

BackgroundDespite progress made in the control of post-operative infections, the incidence of surgical site infections (SSIs) is still high. An improper perioperative antibiotic use can expose patients to the risk of resistant microorganisms, and, in surgical obese patients, the drug dosage and infusion time are critical points. The aim of our study was to evaluate the effectiveness of ertapenem in the prophylaxis of SSIs in obese patients undergoing general or bariatric surgery.MethodsA total of 63 obese patients, candidates for several surgical interventions, were enrolled and divided into two groups. Patients received antibiotic prophylaxis before surgery: the case group received venous infusion of ertapenem; the control group received standard prophylaxis. Serum samples were tested for antimicrobial activity against Gram-positive and Gram-negative bacteria.ResultsAfter single-dose ertapenem in obese patients, we registered in vitro activity of sera against the growth of non-extended beta lactamase (ESBL)-producing Escherichia coli, Proteus mirabilis, Citrobacter freundii, Enterobacter cloacae, and non-ESBL-producing Klebsiella pneumoniae. Moreover, methicillin-sensitive Staphylococcus aureus and Streptococcus viridans were also inhibited. We found in vivo efficacy according to clinical monitoring: at the weekly and monthly follow-ups, one patient in the case group and six patients in the control group presented superficial incisional SSIs.ConclusionsThese preliminary results are suggestive of the efficacy of ertapenem in perioperative prophylaxis of SSIs in obese patients; however, they need to be confirmed by further investigations and more defined trials.