Ilan Charuzi

Obstructive Sleep Apnea in the Obese

Abstract. Obstructive sleep apnea (OSA) syndrome occurs in 4% to 9% of middle-aged men and in 1% to 2% of middle-aged women. The incidence of OSA among morbidly obese patients is 12- to 30-fold higher. The pathophysiology of OSA is complex and incompletely understood. The important clinical symptoms of OSA include snoring, daytime sleepiness, restless sleep, morning fatigue, and headaches. The diagnosis is made by polysomnography. The possible sequelae of OSA are hypertension, left and right ventricular hypertrophy, sudden cardiovascular death, and increased risk for brain infarction. Nasal continuous positive airway pressure (nCPAP) appears to be the recommended treatment for OSA. Morbidly obese patients may also benefit from weight reduction gastric surgery.

Seroma after laparoscopic repair of hernia with PTFE patch : is it really a complication?

Abstract.We evaluated the true incidence of seroma formation after laparoscopic repair of incisional hernia with polytetrafluoroethylene (PTFE) patch. In a prospective study, 20 patients who underwent laparoscopic repair of incisional hernia with PTFE were evaluated clinically and with ultrasound examination for seroma formation up to the 90th postoperative day. Seroma was diagnosed clinically in only 35% of cases, while ultrasound examination revealed the presence of seroma in 100% of patients. Ultrasound examination is a reliable tool for diagnosis of early or delayed postoperative seroma formation following laparoscopic repair of incisional hernia with Gore-Tex Dualmesh.

Laparoscopic repair of postoperation ventral hernia Early postoperation results

AbstractBackground: Laparoscopic repair is a new alternative approach to postoperation ventral hernia (POVH). Whether this procedure is accompanied with acceptable operation risk and recurrence rate is not yet established. Methods: During 1996, we performed laparoscopic repair of POVH in 53 patients. Twenty-nine (55%) of these patients had a history of at least one failed hernia repair. The size of the abdominal wall defect varied from 4 × 5 cm to 15 × 20 cm (median, 13 × 9 cm). All operations were performed with the patient under general anesthesia. In all cases, the Gore-Tex® Dual Mesh (W. L. Gore & Associates, Flagstaff, AZ, USA) was used in sizes varying from 5 × 7 cm to 20 × 30 cm (median, 15 × 12 cm). Results: No deaths occurred as a result of the operations. Intraoperative small bowel injury occurred in two patients (3.6%), which necessitated conversion to laparotomy and performance of small bowel resection in one case and simple suture in the other. Small bowel obstruction developed during the immediate postoperation period in two patients (3.6%). In one of these patients, laparoscopic lysis of adhesions had to be performed. Graft infection with subsequent graft removal occurred in one patient (1.8%), and abdominal wall hematoma developed in another patient (1.8%). Length of hospital stay varied from 2 to 8 days (median, 3.3 days). Follow-up period ranged from 10 to 22 months (median, 17 months). During this period, recurrence of hernia occurred only in one patient in which the mesh had been removed. Conclusions: Laparoscopic repair of POVH is technically feasible. According to our experience, it is the preferred method for patients who have had an earlier failed open repair and patients in whom it is the first repair. Cases with a high likelihood for small bowel injury must be recognized and converted to routine open repair.

Inhibin B in men with severe obesity and after weight reduction following gastroplasty.

Although the effect of obesity on some gonadal functions in men is known, its effect on Sertoli cell function has not been reported. We tested the hypothesis that the serum inhibin B level is decreased in men with severe obesity, and that this change persists after significant weight loss. We measured gonadal hormones in 17 obese men before (baseline) and after weight reduction following silastic ring vertical gastroplasty (SRVG). Their baseline body mass index (BMI) was 44.3 ± 1.7 kg/m2, mean ± standard error of the mean (SEM). Seven of 16 obese men (44%), compared to 8 of 69 reference men (12%), had a baseline inhibin B level below 100 pg/ml (p < 0.01). A weak inverse association was found between inhibin B and BMI before weight reduction (r = −0.494, p = 0.072). Furthermore, FSH levels, which were weakly inversely associated with inhibin B levels (r = −0.482, p = 0.059), were inappropriately unelevated in 5 of the 7 obese men with low (below 100 pg/ml) inhibin B. After a weight reduction of 40 ± 2.6 kg, mean ± SEM, following surgery, the obese men’s BMI was 31.6 ± 1.5 kg/m2, mean ± SEM, and inhibin B normalized in 3 of the 7 patients with low inhibin B. Despite weight reduction, FSH remained inappropriately unelevated in 2 of the 4 patients whose inhibin B remained low. This study also confirmed previously published findings that obese men have low serum total and free testosterone and relative hypogonadotropic (low LH) hypogonadism that may persist after weight reduction. In conclusion, Serum inhibin B levels in obese men may be low. This may be due to relative hypogonadotropic (also low FSH) hypogonadism.

Access-Port Complications after Laparoscopic Gastric Banding

Background: The aim of this retrospective study was to identify complications related to the access-port, after Lap-Band® system placement by laparoscopy. Methods: The records of 333 morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB) were reviewed for the overall surgical complications. Data was further analyzed regarding the complications related to the access-port. Results: From January 1999 to December 2001, the overall complication-rate with the LAGB was 25.8%. 45 complications (13.5%) were related to the accessport in 34 patients following LAGB placement.The 45 access-port complications were distributed as follows: infection 51.1%, tubing disconnection 17.7%, dislodgment of the access-port 15.6%, leak of the reservoir 11.1%, and skin ulceration by the port 4.45%. Conclusion: The integrity of the Lap-Band® system is essential to achieve the objective of the operation: weight loss. Complications related to the access-port were relatively frequent, but preventable.

The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture

AbstractBackground: Diaphragmatic rupture is one of the most commonly missed injuries in trauma cases. Traditionally, laparotomy or thoracotomy has been the treatment of choice for this condition. Methods: During the last 2 years, we treated three patients laparoscopically to address neglected diaphragmatic ruptures that caused herniation of the intraabdominal contents. Results: In all three cases, laparoscopy succeeded in identifying the diaphragmatic defect, so that the herniated viscera could be released and the defect repaired primarily or with a prosthesis. The intraoperative and the postoperative courses were uneventful; there were no significant complications. Conclusion: Laparoscopy has an important role in the surgical treatment of missed diaphragmatic ruptures.

Laparoscopic repair of access port site hernia after Lap-Band® system implantation

Background: The appearance of hernia around the access port site after implantation of a laparoscopic adjustable gastric band (LAGB) is a complication that can limit the beneficial effect of the device. We evaluated the incidence of hernias at the port-site for band adjustment and propose a technique for its repair. Methods: A retrospective study was conducted of 459 patients who underwent LAGB system implantation for treatment of morbid obesity between January 1999 and July 2001.We recorded all complications that occurred following LAGB placement, with special emphasis on port site hernia. Results: 3 out of the 459 patients (0.65%) had a hernia at the site where the reservoir had been implanted. The use of a trocar >11 mm should be avoided to prevent this complication. We describe our technique of repair of the hernia by intraperitoneal detachment and pulling of the access reservoir into the peritoneal cavity, intraperitoneal repair of the defect with Gore-Tex® Dual mesh, and reimplantation of the reservoir. Conclusions: Our technique successfully repaired the hernia, and enabled continuation of adjustments to the gastric band.

Use of Adjustable Silicone Gastric Banding for Revision of Failed Gastric Bariatric Operations

Background: Revision of gastric bariatric operations is sometimes technically difficult and may fail to achieve prolonged weight reduction. The use of the adjustable silicone gastric banding (ASGB) offers a new approach for these revisions. Methods: ASGB was performed as a revisional procedure on 37 patients whose initial bariatric operations were as follows: silastic ring vertical gastroplasty (21), gastric bypass (12), horizontal gastroplasty (3) and vertical banded gastroplasty (1). Results: The length of the procedure varied from 55 to 145 minutes (mean 83 minutes). Intraoperative complications included two fundic tears which were sutured without any postoperative sequelae. Five patients needed reoperation during the first postoperative year due to gastric volvulus (1), tubing tear (1) and development of postoperative ventral hernia (3). BMI fell from 44.8 ± SD 8.07 to 33.4 ± 6.9 kg/m2 for patients operated with BMI higher than 35 kg/m2 and from 29.2 ± 3.32 to 25.4 ± 2.8 kg/m2 for patients operated with BMI lower than 35 kg/m2. Conclusions: ASBG can be performed with revisions with an acceptable complication rate and post-operative weight reduction.

Silastic RingVertical Gastroplasty by Minilaparotomy

Background: The incision length has significant influence on the postoperative course after silastic ring vertical gastroplasty (SRVG). Methods: A technique is described in which SRVG can be performed through a minilaparotomy incision. Results: 110 patients were operated with this technique during 1996. No remarkable intraoperative or postoperative complications were encountered. Postoperative weight loss has been satisfactory. Conclusions: Performance of SRVG through a minilaparotomy is feasible. The technique is recommended for surgeons familiar with the operation through the formal incision.

Laparoscopic repair of inguinoscrotal hernia with complete herniation of the urinary bladder

SummaryWe describe a rare case of complete herniation of the urinary bladder into a groin hernia. The hernia was operated successfully using the laparoscopic approach.