Felix B. Langer

Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels.

Background: Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion. Methods: This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients. Results: Patients who underwent LSG (n=10) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 ± 12.3 fmol/ml vs 109.6 ± 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 ± 35.3 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.441) was found in patients after LAGB (n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 ± 30.3 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.028) and 6 months (104.9 ± 51.1 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 ± 13% vs 17 ± 7%, P=0.005) and 6 months (61 ± 16% vs 29 ± 11%, P=0.001) compared with the LAGB group. Conclusions: As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.

Does Gastric Dilatation Limit the Success of Sleeve Gastrectomy as a Sole Operation for Morbid Obesity

Background: Sleeve gastrectomy as the sole bariatric operation has been reported for high-risk super-obese patients or as first-step followed by Roux-en-Y gastric bypass (RYGBP) or duodenal switch (DS) in super-super obese patients. The efficacy of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients with a BMI of <50 kg/m2 and the incidence of gastric dilatation following LSG have not yet been investigated. Methods: 23 patients (15 morbidly obese, 8 super-obese) were studied prospectively for weight loss following LSG. The incidence of sleeve dilatation was assessed by upper GI contrast studies in patients with a follow-up of >12 months. Results: Patients who underwent LSG achieved a mean excess weight loss (EWL) at 6 and 12 months postoperatively of 46% and 56%, respectively. No significant differences were observed in %EWL comparing obese and super-obese patients. At a mean follow-up of 20 months, dilatation of the gastric sleeve was found in 1 patient and weight regain after initial successful weight loss in 3 of the 23 patients. Conclusion: LSG has been highly effective for weight reduction for morbid obesity even as the sole bariatric operation. Gastric dilatation was found in only 1 patient in this short-term follow-up. Weight regain following LSG may require conversion to RYGBP or DS. Follow-up will be necessary to evaluate long-term results.

After massive weight loss: patients' expectations of body contouring surgery.

BackgroundMassive weight loss following bariatric surgery leads to excess skin with functional and aesthetic impairments. Surplus skin can then contribute to problems with additional weight loss or gain. The aims of the current study were to evaluate the frequency of massive soft tissue development in gastric bypass patients, to determine whether males and females experience similar post-bypass body changes, and to learn about the expectations and impairments related to body contouring surgery.MethodsA questionnaire addressing information on the satisfaction of body image, quality of life, and expectation of body contouring surgery following massive weight loss was mailed to 425 patients who had undergone gastric bypass surgery between 2003 and 2009. Of these 425 individuals, 252 (59%) patients completed the survey.ResultsNinety percent of women and 88% of men surveyed rated their appearance following massive weight loss as satisfactory, good, or very good. However, 96% of all patients developed surplus skin, which caused intertriginous dermatitis and itching. In addition, patients reported problems with physical activity (playing sports) and finding clothing that fit appropriately. Moreover, 75% of female and 68% of male patients reported desiring body contouring surgery. The most important expectation of body contouring surgery was improved appearance, followed by improved self-confidence and quality of life.ConclusionsSurplus skin resulting from gastric bypass surgery is a common issue that causes functional and aesthetic impairments in patients. Consequently, this increases the desire for body contouring surgery with high expectations for the aesthetic outcome as well as improved life satisfaction.

The Prevalence of Body Contouring Surgery After Gastric Bypass Surgery

BackgroundAs bariatric surgery has become more popular, more patients are undergoing body contouring surgery after massive weight loss. Many of the surgical procedures performed on the massive weight loss patient are complex and labor-intensive. Therefore, the plastic surgery unit needs to be prepared for a patients demand. Little literature is available on how frequently patients who have undergone gastric bypass surgery receive body contouring surgery.MethodsTwo hundred fifty-two subjects (out of 425 who were mailed the questionnaire) who had undergone gastric bypass surgery between 2003 and 2009 completed the questionnaire, which obtained information on body image satisfaction and frequency of body contouring surgery after massive weight loss.ResultsOf all patients, 74% desire a body contouring surgery after gastric bypass surgery. Fifty-three patients (21%) have undergone a total of 61 body contouring procedures. The most common were abdominoplasties (59%), followed by lower body lifts (20%). In contrast to a positive judgment of the general aspect of the body image satisfaction after massive weight loss, both genders are unsatisfied with body areas like abdomen/waist, breast, and thighs.ConclusionsParalleling the increasing use of bariatric surgery, there is a high demand for body contouring surgery. A huge disparity exists between the number of subjects who desire a body contouring surgery and those who actually received it.

Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test

BACKGROUND Neuroglucopenic hypoglycemia might be an underestimated threat for roux-en-Y gastric bypass (RYGB) patients leading to fatigue, syncope, seizures or even accidental deaths. Different measurements can assess hypoglycemia such as a finger-stick glucometer, an Oral Glucose Tolerance Test, a Mixed Meal-Test (MMT) or, as introduced recently, continuous glucose monitoring (CGM). SETTING University Hospital, Austria. METHODS To assess the incidence of hypoglycemic episodes under real life conditions, 5-day CGM was performed in a series of 40 patients at a mean of 86 months after RYGB. The detection rates were compared to a mixed meal-test. RESULTS CGM detected hypoglycemic episodes of <55 mg/dL or <3.05 mmol/L in 75% of the patients, while MMT indicated hypoglycemia in 29% of the patients. CGM also detected nocturnal hypoglycemic episodes in 15 (38%) of the patients. A mean of 3±1 hypoglycemic episodes per patient with a mean duration of 71±25 minutes were observed by CGM. CONCLUSIONS Assessed under real life conditions by CGM, post-RYGB hypoglycemia was found more frequently than expected. CGM revealed hypoglycemic episodes in 75% of the patients while MMT had a lower detection rate. Thus, CGM may have a role for screening but also for the evaluation of dietary modifications, drug therapy or surgical intervention for hypoglycemia after RYGB.

Esophageal cancer: International guidelines in interdisciplinary diagnosis and treatment

ZusammenfassungGRUNDLAGEN: Diagnostik, Staging und Therapie des ösophaguskarzinoms sind eine interdisziplinäre Herausforderung. Dieser Übersichtsartikel soll die Leitlinien von internationalen Gesellschaften über das Management von ösophagealen Malignomen zusammenfassen. METHODIK: Leitlinien von sieben onkologischen und chirurgischen Organisationen wurden fusioniert. ERGEBNISSE: Die chirurgische Therapie bietet in frühen Stadien als einzige Modalität die komplette Tumorentfernung, birgt aber beträchtliche Morbidität. Auch mit der Strahlentherapie kann Langzeitüberleben erreicht werden. Beim lokal fortgeschrittenen Karzinom werden aufgrund der schlechten Prognose multimodale Konzepte aufgegriffen. SCHLUSSFOLGERUNGEN: In dieser Übersicht werden die Leitlinien von sieben internationalen Gesellschaften zu einem Kompendium der Behandlung des ösophaguskarzinoms zusammengefasst.SummaryBACKGROUND: Diagnostic and therapeutic management of esophageal cancer is a multidisciplinary challenge. This article aims to highlight guidelines of international societies and networks for esophageal malignancies. METHODS: Guidelines of 7 international cancer organisations were reviewed and merged. RESULTS: Surgery is the single modality offering complete tumour clearance in early stages but bears remarkable morbidity. Also after radiotherapy, long-term survival may be reached. In advanced stages multimodal strategies have been adopted since prognosis is poor. CONCLUSIONS: In this article the guidelines of seven international societies and networks are collected offering a summary of recommendations in esophageal cancer care.

Outcome and complications of long‐term self‐expanding esophageal stenting

Esophageal stenting with self-expanding plastic or covered metal stents is believed to be safe and effective. As data on the outcome of patients with long-term stenting are not available, this study was conducted to evaluate the safety and efficacy of long-term esophageal stenting. From 2002 to 2008, 70 patients with long-term esophageal stenting for various indications from a prospective database were included into further analysis. The median stent period was 297 (124-1980) days during a mean follow-up time of 55 ± 52.4 months. Overall complication rate was 30% with a primary success rate of 97.2%. The stent-related total reintervention rate was 17.1%. There were no correlations between stent characteristics and the risk of complication or migration. No stent-related death was observed. Our data provide evidence that long-period esophageal stenting is safe and effective for various indications.

HER-2 status in primary oesophageal cancer, lymph nodes and distant metastases

Some 10–15 per cent of patients with oesophageal cancer overexpress human epidermal growth factor receptor (HER) 2 at the primary tumour site, leading to the hope that specific targeted systemic therapy might favourably influence clinical and subclinical disease at locoregional and distant sites. This approach is based on primary tumour characteristics, without knowledge of expression patterns at metastatic sites. In oesophageal cancer, concordance between HER‐2 status at the primary tumour and other sites is unknown.

Solving the Problem of Difficult Stent Removal Due to Tissue Ingrowth in Partially Uncovered Esophageal Self-Expanding Metal Stents

Partially uncovered stents provide a better fixation to the esophageal wall than fully covered stents, but indication is limited to palliation because stent removal is compromised by mucosal ingrowth. After an unsuccessful attempt to remove a partially uncovered Evolution stent (Cook Medical Inc, Bloomington, IN) we placed a Polyflex stent (Boston Scientific, Natick, MA) inside the first stent, overlapping at the lower part to press the tissue out of the stent mesh. Both stents were easily removed 3 days later. By adopting this procedure to scheduled stent removals, partially uncovered SEMS may be used to prevent the frequently observed migrations of fully-covered stents in the treatment of esophageal perforation or anastomotic leakage.

Parenchymal liver injury in orthotopic liver transplantation.

BACKGROUND A 35-year period of clinical development resulted in orthotopic liver transplantation (OLT) becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high. Although the main problem in most analyses is vascular or bile duct failure, we observed a remarkable number of parenchymal liver injuries that led to intraoperative problems. Our aim, therefore, is to present an overall report on the incidence, treatment, and clinical course of parenchymal liver injuries in OLT. METHODS Five hundred seventy-two consecutive OLT procedures performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. Donor- and recipient-related data followed the medical report. The lesions were classified according to the Organ Injury Scale. RESULTS Parenchymal liver injury was diagnosed in 23 patients (4%). The lesions were classified as grade Ia (13.1%), grade Ib (13.1%), grade IIb (52.1%), grade IIIa (17.1%), and grade IIIb (4.3%). In 19 patients (82.6%), the lesion was detected during OLT, and in four patients (17.4%), during relaparotomy. The latter group showed significantly higher-grade injuries. Treatment was suture or fibringlue alone, 17.4%; fibringlue and hemostyptics, 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy. Further active bleeding was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate. No patients died as a result of parenchymal liver injury. CONCLUSIONS Parenchymal liver injuries can be treated well, with no adverse effect on patient or graft survival. An early decision concerning the surgical procedure for controlling hemorrhage is required. A basically aggressive therapeutic approach might avoid further complications relating to reperfusion edema.