Benjamin Person

Nutritional Deficiencies in Morbidly Obese Patients: A New Form of Malnutrition? : Part A: Vitamins.

It is a common belief that clinical vitamin or mineral deficiencies are rare in Western countries because of the low cost and unlimited diversity of food supply. However, many people consume food that is either unhealthy or of poor nutritional value that lacks proteins, vitamins, minerals, and fiber. In this, article we reviewed the literature and highlighted the vitamin deficiencies in obese patients before bariatric surgery. Deficiency of dietary minerals is described in the accompanying manuscript. The prevalence of vitamin deficiencies in the morbidly obese population prior to bariatric surgery is higher and more significant than previously believed.

Comparison of four energy-based vascular sealing and cutting instruments: A porcine model

AimTo compare the safety and efficacy of four energy-based vascular sealing and cutting instruments.MethodsBlood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE™ (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure™ V and LigaSure Atlas™ (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal™ vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury.ResultsThe bursting pressures were significantly higher with EnSeal™ compared to all other instruments (p < 0.0001). The sealing process was significantly shorter with Harmonic ACE™ and significantly longer with LigaSure Atlas™ (p <0.0001). The mean seal width was larger with the LigaSure Atlas™ compared to the other instruments, and it was smaller with EnSeal™ and Harmonic ACE™. Less radial adventitial collagen denaturation was present with EnSeal™ and LigaSure™ V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas™ than with the other instruments; however, the numbers were too small for statistical analysis.ConclusionsThe bursting pressures with EnSeal™ were significantly higher than with all the other instruments. Harmonic ACE™ was the fastest sealing instrument and LigaSure Atlas™ was slowest. EnSeal™ created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas™ created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

Nutritional Deficiencies in Morbidly Obese Patients: A New Form of Malnutrition?

Even though in the Western world there is almost no limitation to a wide variety of food supply, nutritional deficiencies can be found in both normal-weight population and in the obese population. In this review, we examine the prevalence and manifestations of various mineral deficiencies in obese patients.

Compression anastomosis: history and clinical considerations

BACKGROUND Despite the fact that the concept of compression anastomosis has been investigated for nearly 2 centuries, it has not yet achieved widespread acceptance. The aim of the current report is to review the literature regarding compression anastomoses. DATA SOURCES A multi-database search was conducted using PubMed, Ovid, and the Cochrane Databases (all until June 2007), in addition to electronic links to related articles and references of selected articles. The following terms were used for the search in various combinations: anastomosis, anastomoses, sutureless, compression, nickel-titanium; Nitinol; CAC; CAR; AKA-2, Valtrac biofragmentable anastomotic ring, BAR. Language restrictions were not applied. CONCLUSIONS The various methods of compression anastomosis have been shown to be at least comparable to the standard techniques of suturing and stapling. The measurement of outcomes, including cost, safety, and efficacy of treatment, indicated that compression anastomosis can save time, is cost-effective, and offers an acceptable cost/benefit ratio compared to both stapled and sutured anastomoses. However, compression anastomosis did not gain worldwide popularity.

Do elderly patients benefit from laparoscopic colorectal surgery

BackgroundThe steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients.AimTo analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP).MethodsA retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age ≥ 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality.Results641 patients (M/F – 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 – 60%) than in group B (106/234 – 45%) – p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3–17) days versus 8.7 (4–22) days in group B (p <0.0001), and LAP: 5.3 (2–19) days versus 6.4 (2–34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003).ConclusionsElderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.

The impact of preoperative stoma site marking on the incidence of complications, quality of life, and patient's independence.

BACKGROUND: Preoperative stoma site marking and counseling aim to improve patients’ rehabilitation and adaptation to a new medical condition. Objective studies are needed to provide evidence of the impact of care by stoma therapists. Key quality indicators include patients’ quality of life, independence, and complication rates as affected by the variable modes of stoma site marking and planning. OBJECTIVE: The aim of this study was to evaluate the impact of preoperative stoma site marking on patients’ quality of life, independence, and complication rates. DESIGN: A validated stoma quality-of-life questionnaire was used as the main assessment tool. Complications were noted on regular postoperative visits. SETTING: This is a single-center, clinical study. The study was conducted at the Rambam Health Care Campus in Haifa, Israel. Rambam Health Care Campus is a tertiary university hospital. PATIENTS: All patients who underwent an elective stoma creation between 2006 and 2008 were included. MAIN OUTCOME MEASURES: Evaluated parameters included demographics, stoma type, marking status, complication rates, quality of life, and independence parameters. RESULTS: One hundred five patients (60 men and 45 women) were included, of whom 52 (49.5%) were preoperatively marked and 53 (50.5%) were not marked. Sixty stomas (57%) were permanent, and 45 (43%) stomas were temporary. The quality of life of patients whose stoma sites were preoperatively marked was significantly better than that of the unmarked patients (p < 0.05 in 18 of 20 items), their independence parameters were significantly better, and their complication rates significantly lower. All of these results were significant irrespective of the stoma type. CONCLUSIONS: Preoperative stoma site marking is crucial for improving patients’ postoperative quality of life, promoting their independence, and reducing the rates of postoperative complications. The role of the enterostomal therapist is very important in the ostomates’ pre- and postoperative care.

What Are the Outcomes of Reoperative Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis Surgery?

PURPOSE: Restorative proctocolectomy and ileal pouch-anal anastomosis is the current surgical treatment of choice for most patients with ulcerative colitis. Complications of the ileal pouch may necessitate additional operations to salvage the pouch. The aims of this study were to review the outcomes of reoperative restorative proctocolectomy and ileal pouch-anal anastomosis surgery and to define any predictors of successful pouch salvage surgery. METHODS: The medical records of all patients who underwent reoperative ileoanal pouch surgery for either pouch salvage or pouch excision between 1988 and 2007 were reviewed. Successful ileoanal pouch salvage was considered to be an intact functioning pouch, after resolution of problem, with a follow-up of at least six months and good to excellent patient satisfaction and continence. RESULTS: Fifty-one patients underwent reoperation for pouch-related complications (44 mucosal ulcerative colitis, 6 familial adenomatous polyposis, and 1 indeterminate colitis), in addition to 8 patients with Crohns disease. An additional 17 patients had primary pouch excision. Thirty-eight (74.4 percent) of the 51 patients who underwent pouch salvage had a successful outcome. Twenty-three patients had pouch reconstruction or revision via an abdominal approach with a 69.5 percent success rate. The remainder of patients had local perineal procedures for control of perianal sepsis, with 75 percent success rate. Patients required a mean of 2.1 procedures to achieve pouch salvage; there was no correlation between the number of ileoanal pouch salvage procedures and failure. Crohns disease was ultimately diagnosed in more than half of the patients who underwent primary pouch excision. Among the patients with Crohns disease who underwent pouch salvage only three retained their pouches, for a success rate of only 37 percent. CONCLUSION: Ileal pouch-anal anastomosis salvage surgery can save a considerable number of patients from pouch excision and permanent ileostomy. Both local perineal and abdominal approaches yield acceptable results. The choice of procedure is based on the etiology and anatomy of the problem and the surgeons preference and patient-related factors such as diagnosis.

Biofeedback therapy for rectal intussusception

BackgroundSurgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception.MethodsWe retrospectively evaluated the results of electromyography (EMG)–based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder.ResultsA total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean±SD) was 2.0±6.8 before and 4.1±4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8±3.5 before to 1.5±2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty–three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were consti– pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0±0.7 before to 0.07±0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1±4.2 before to 4.6±3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group.ConclusionsBiofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long–standing constipation is less effectively cured by biofeedback.

Advances in the Surgical Treatment of Fecal Incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.

Totally laparoscopic low anterior resection with transperineal handsewn colonic J-pouch anal anastomosis for low rectal cancer

The treatment of tumors in the middle and lower thirds of the rectum has evolved from palliative diversion for obstructing lesions to abdominoperineal resection (APR), which represented the ‘‘gold standard’’ in the first half of the 20th century [2], to sphincter-preserving procedures such as restorative proctectomy with or without creation of a colonic J-pouch. Laparoscopic surgery represents the latest advance in the surgical treatment of rectal cancer. These technically demanding procedures are gaining increasing popularity, with laparoscopic proctectomies and APRs currently performed routinely in numerous centers throughout the world [1, 3–6]. This article presents a modification of laparoscopic restorative proctectomy, which in the authors opinion represents a further advancement in surgery for low rectal tumors. This technique includes laparoscopic mobilization of the left colon, sigmoid colon, splenic flexure, and rectum; intracorporeal vascular division; transperineal transection and excision of the rectosigmoid; extracorporeal transperineal creation of a colonic J-pouch; and a handsewn anastomosis of the J-pouch to the anus.