Federico Famiglietti

10-year follow-up of laparoscopic vertical banded gastroplasty. Good results in selected patients

Objective:To evaluate the long-term results of laparoscopic vertical banded gastroplasty (VBG) for morbid obesity. Background:Laparoscopic VBG, a safe and straightforward bariatric procedure characterized by good short-term results, has been progressively replaced by other more complex procedures on the basis of a presumed high rate of long-term failure. Nevertheless, some authors have recently reported long-term efficacy in selected patients. Methods:All patients who underwent laparoscopic VBG were included in a prospective database. Patients reaching 10-year follow-up received a complete evaluation including clinical, endoscopic, and biochemical examinations. Results:Between January 1996 and March 1999, 266 morbidly obese patients underwent bariatric procedures. Among them, 213 were selected for laparoscopic VBG; exclusion criteria were as follows: contraindications to pneumoperitoneum, gastroesophageal reflux disease, and psychological contraindications to restrictive procedures. Mean age, preoperative weight, and body mass index were 36.9 years, 123.6 kg, and 45.4 kg/m2, respectively. Intraoperative complication rate and conversion rate were 0.9% and 0.9%, respectively. Early postoperative complication rate was 4.2% and early reoperation rate was 0.5%. Mean hospital length of stay was 6.3 days. Mortality was nil. The 10-year follow-up rate was 70.4% (150 patients). Late postoperative complication rate was 14.7%, and 10-year revisional surgery rate was 10.0%. The excess weight loss percentages at 3, 5, and 10 years were 65.0%, 59.9%, and 59.8%, respectively. The resolution and/or improvement rate for comorbidity were 47.5% for hypertension, 55.6% for diabetes, 75% for sleep apnea, and 47.4% for arthritis. Mean Moorehead-Ardelt Quality of Life Questionnaire and BAROS values were 1.4 and 3.8, respectively. Conclusions:The present study demonstrates that laparoscopic VBG in carefully selected patients leads to long-term results comparable with more complex and invasive procedures. Given the low postoperative morbidity for laparoscopic VBG, its present clinical role should be, in our opinion, reevaluated.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) and colorectal cancer

Surgical techniques and technologies are rapidly evolving. In the field of colorectal surgery the transanal video‐assisted approach was introduced by Buess, 30 years ago, with transanal endoscopic microsurgery (TEM). In more recent years different techniques and technologies have been proposed, including natural orifice specimen extraction (NOSE), natural orifice transluminal endoscopic surgery (NOTES) and single‐access surgery. Furthermore, a better understanding of the prognostic and risk factors of rectal cancer has allowed TEM to expand its indications to local resection of selected tumours, and more recently there have been proposals for sentinel node biopsy in colon and rectal cancer.

Rectal lymphogranuloma venereum

A 42-year-old man was referred by his gastroenterologist after endoscopy with a suspected rectal neoplasm. For 2 months he had complained of anorectal pain, bleeding, mucous discharge, tenesmus and constipation. Digital rectal examination showed rectal stenosis and endoscopy revealed an ulcerating bleeding mass between 7 and 10 cm from the anal verge (Fig. 1). Multiple biopsies showed granulation tissue. On further questioning, the patient reported unprotected receptive anal intercourses with multiple male partners, also while abroad in the UK and Spain. He was on antiretroviral therapy (raltegravir and atazanavir) for human immunodeficiency virus (HIV) stage A1 infection. The CD4 cell count was 550 ⁄ mm and the HIV viral load was undetectable. Gram staining of a rectal smear showed more than 30 polymorphonuclear leucocytes per highpower field. A rectal swab processed with a COBAS TaqMan CT Test version 2.0 (Roche, Branchburg, New Jersey, USA) for qualitative detection of Chlamydia trachomatis DNA, tested positive for C. trachomatis. An ‘in-house’ genovar-specific nucleic acid amplification test demonstrated lymphogranuloma venereum (LGV) C. trachomatis infection [1]. Treatment with doxycycline (100 mg twice daily for 21 days) resolved the symptoms within 15 days. Follow-up proctoscopy confirmed complete healing. At 12 months the patient was disease free.

Minimally Invasive Combined Surgery: Liver and Colon-Rectum

Minimally invasive combined colorectal and liver resection is indicated for both benign (diverticular disease, colonic adenoma unsuitable for endoscopic resection, benign liver lesions) and malignant (primary colorectal cancer, hepatocellular carcinoma or HCC, colorectal liver metastases) etiologies. However, whereas reports for benign diseases are sporadic [1], most of the studies published show results of the combined minimally invasive approach to primary colorectal cancer (CRC) with synchronous liver metastases (SLM) [2–7].

Laparoscopic‐endoscopic rendezvous versus preoperative endoscopic sphincterotomy for common bile duct stones in patients undergoing laparoscopic cholecystectomy

This is the protocol for a review and there is no abstract. The objectives are as follows: This review will compare the classical two-stage approach (endoscopic sphincterotomy followed by laparoscopic cholecystectomy) and the single-stage laparo-endoscopic rendezvous technique and cholecystectomy for the treatment of cholelithiasis and common bile duct stones.

Should laparoscopic colorectal surgery still be considered unsafe

W e read with interest the paper by Sammour and colleagues1 comparing laparoscopic to open colorectal surgery in terms of intraoperative complication rates. On the basis of their analysis, the authors concluded that their results “clearly indicate a significantly higher rate of intraoperative complications during laparoscopic colorectal surgery,” mainly due to an increased rate of intraoperative bowel injury. In spite of the unexceptionable methodology of the statistical analysis, the way the study was performed raises several concerns. First, even according to the stated inclusion criteria, study selection seems to have missed at least some consistent data as reported by other authors.2–4 Second, only 10 of 30 studies for which authors forwarded the missing data on intraoperative complications were included in the analysis. This might be comparable to an inappropriate selection bias as it meant the exclusion of more than onethird of cases potentially available. Finally, despite the inclusion of a variety of indications, heterogeneity was almost constantly low to moderate, which might be explained by the rarity of the events considered. From the clinical point of view, even though the total intraoperative complication rate was significantly lower in open surgery, the variables considered (ie, bowel injury defined as any hollow viscus injury requiring repair) lack both a clear clinical relevance and severity. How a difference of less than 1% in risk of bowel injury might affect a patient’s clinical course is questionable. There is now a consistent body of literatureshowing that laparoscopic colorectal surgery, although associated with longer operative times than open colorectal resection, is also associated with a shorter hospital stay, equivalent or improved morbidity, and in the early postoperative period, with better quality of life.5,6 Moreover,