G. Schoretsanitis

Obesity-Associated Disorders Before and After Weight Reduction by Vertical Banded Gastroplasty in Morbidly vs Super Obese Individuals

Background: The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities. Methods: 125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded. Results: Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53% , 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight. Conclusion: Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.

Primary hydatid cyst of the adrenal gland.

An extremely rare case of primary hydatid cyst of the adrenal gland is reported. Adrenal hydatid cysts are usually a manifestation of generalized echinococcosis. Only nine primary cases have so far been reported in the literature. The presentation is insidious. Correct preoperative diagnosis is difficult. Clinical and investigative findings are non-specific and ambiguous. Surgery is the treatment of choice.

Staple-line Disruption Following Vertical Banded Gastroplasty

Background: The purpose of this study was to determine the frequency with which staple-line disruption occurs following vertical banded gastroplasty (VBG) in morbidly obese patients, to investigate the effect of this complication on weight loss, and to identify any clinical symptoms that might be associated with staple-line disruption. Methods: From April of 1992 to June of 1994, 60 patients with morbid obesity underwent VBG. Double-contrast radiographic examination of the upper gastrointestinal tract was performed on all patients at 6, 12, 24, and 36 months postoperation to assess the integrity of the staple line. At these same times, the weight of each patient was measured, so that the patients found to have staple-line disruption could be compared to those without disruption in terms of weight loss. Results: Over the duration of the study, staple-line disruption was found in 12 patients (20%). All of these patients demonstrated satisfactory weight loss. Between the group of patients with staple-line disruption versus the group without disruption, weight loss did not differ significantly at any time up to 3 years postoperation. In addition, in the patients with staple-line disruption, no clear symptomatology that might be associated with this complication was discovered. Conclusions: Our results lead to the conclusion that small disruptions in the staple line lack clinical importance and do not significantly affect weight loss for at least the first 3 postoperative years. Furthermore, staple-line disruption does not seem to be associated with any specific clinical symptoms. Follow-up of all patients via barium meal is the correct approach for discovering the exact incidence of this complication.

Cysts of the adrenal gland: diagnosis and management.

ObjectiveCysts of the adrenal gland are rare, but with the wider application of sonography and computed tomography more adrenal cysts are detected incidentally. To gain more insight into this entity, five such cases are reported and their diagnostic approach and management are discussed.Patients and methodsThe records of five patients with six cysts of the adrenal glands seen at our department from 1987 till 1995 are reviewed. There were four males and one female and their age ranged from 24 to 72 years, with a mean age of 43 years. One patient had a primary hydatid cyst of the right adrenal gland, which was preoperatively thought to arise from the liver or the right kidney. A second patient had a very large pseudocyst of the left adrenal gland, which is the largest ever reported in the literature. The other four cysts in three patients were found incidentally during sonography or computed tomography.ResultsThe hydatid cyst with a rim of normal adrenal tissue was excised. The large pseudocyst was removed together with the adrenal gland. In the cases of the incidentally found cysts, observation of the patient with regular follow-up was decided upon. All patients are in good condition and without symptoms 2 to 10 years after the initial diagnosis.ConclusionsAdrenal cysts are rare and their diagnosis may pose problems. Symptomatic adrenal cysts should be operated, but small, asymptomatic, non-functional cysts with benign characteristics may be treated conservatively with regular follow-up by sonography or computed tomography and hormonal evaluation.

Parathyroid carcinoma: clinical presentation and management

Parathyroid carcinoma constitutes a rare cause of hyperparathyroidism. Five patients, presenting with symptoms and clinical signs of parathyroid hyperfunction, were diagnosed with parathyroid carcinoma in our department over a 12-year period. The experience we gained in the management of these tumors is presented. The aim of this study is to elucidate the clinical features of the disease, the surgical treatment, and the sensitivity of the imaging modalities used to enhance the diagnostic ability. Preoperative recognition and intraoperative identification of this rare endocrine malignancy require a high index of clinical suspicion. Intraoperative awareness is needed of the malignant potential of the encountered lesion.

Does reduction in gastric acid secretion in bariatric surgery increase diet-induced thermogenesis?

Background: Patients who have undergone gastrectomy for benign ulcer do not develop obesity. Furthermore, morbidly obese patients who undergo biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGBP) and vertical banded gastroplasty (VBG) plus truncal vagotomy, may lose more weight compared with patients who undergo VBG alone. A common characteristic of the above is the reduction of gastric hydrochloric acid secretion. We investigated whether reduction in gastric acid increases dietary- induced thermogenesis because of maldigestion of foods, and this may account for the greater weight loss in the above situations. Materials and Methods: 22 volunteers without symptoms from the upper gastrointestinal tract were studied. Gastric pH was measured and resting energy expenditure (MREE), using indirect calorimetry, was determined before and 8 hours after consumption of a standard meal. Parameters were measured again after 2 months administration of proton pump inhibitors in all volunteers. Results: Although significant reduction of gastric acid secretion occurred (p<0.01), following administration of proton pump inhibitors, the fasting and postprandial MREE remained unchanged (p>0.05). Conclusions: The reduction in gastric acid secretion does not increase the energy requirements for digestion of foods and thus is neither the mechanism responsible for the increased weight loss observed after RYGBP or BPD, nor the explanation for the lean appearance of gastrectomized patients.

Pylorus-preserving pancreaticoduodenectomy with external pancreatic remnant drainage.

Abstract Background : Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate. Methods : A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed. Results : There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively. Conclusions : The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including longterm nutritional complications.

Primary psoas abscess. Report of three cases.

Abstract Background: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians. Patients and methods: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36–51 years were admitted with fever, abdominal pain and a palpable tender mass. Results: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor. Conclusions: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.

Neurofibrosarcoma of the duodenum

A case of neurofibrosarcoma of the second part of the duodenum is reported. The presenting symptom was upper GI tract bleeding. An emergency pancreaticoduodenectomy was performed to remove a 6 x 8 cm tumour invading the head of the pancreas and the ampulla of Vater. Histopathologically, a low grade malignant neurofibrosarcoma without lymph node invasion was evident. No adjuvant therapy was judged to be necessary. The patient is well and free of disease 5 years following the resection of the neoplasm.

Experience with benign splenic disease.

Abstract Purpose : In the ongoing effort to improve patient treatment, a deeper understanding of the symptomatology, physical signs and management options of rare splenic, non-traumatic, benign diseases is extremely important. Patients and Methods : The records of eight consecutive patients with benign splenic conditions, other than injury and abscess, were reviewed retrospectively in order to analyse the clinical presentation, diagnostic methodology and therapeutic procedures applied in these rare conditions. Of the eight patients, three were diagnosed with splenic hydatid cyst, two with pseudocysts, one with splenic epider-moid cyst, one with wandering spleen and one with infraction of an ectopic spleen with situs inversus of other intraabdominal organs. Results : Upper abdominal pain was the most common presenting symptom and a tender palpable mass in the left upper abdominal quadrant, the predominant clinical finding. Pre-operative CT scanning confirmed the diagnosis in six patients, but failed to reveal the splenic pathology in the remaining two cases. Seven patients underwent splenectomy while saving splenic parenchyma was feasible in only one patient (12,5%). Conclusions : Splenic, non-traumatic, benign diseases have vague clinical presentation and may create diagnostic difficulties. Although spleen saving intervention can be applied in selected cases, splenectomy would be required in most patients.