Kagan Zengin

Changes in Leptin, Plasminogen Activator Factor and Oxidative Stress in Morbidly Obese Patients following Open and Laparoscopic Swedish Adjustable Gastric Banding

Background: Oxidative stress is increased in obesity, leading to endothelial dysfunction, atherogenesis, and platelet aggregation. The purpose of this study was to determine the effects of weight loss after bariatric surgery on serum lipids, malondialdehyde (MDA, a marker of oxidative stress), oxidized low-density lipoprotein (oxLDL, which is increased in obesity and causes endothelial dysfunction), paraoxonase (PON-1, which inhibits lipid peroxidation), leptin and plasminogen activator inhibitor type-1 (PAI-1, which contributes to a thrombotic state). Methods: 40 morbidly obese patients had insertion of a Swedish adjustable gastric band (SAGB). A lipid profile, MDA, oxLDL, PON-1, leptin and PAI-1 levels were drawn before and 6 months after the operation. 20 patients underwent open (Group 1) and 20 laparoscopic (Group 2) SAGB, to compare the systemic inflammatory response of the two approaches. Results: Patient demographics, indications for surgery, and postoperative results were no different between the groups. Postoperative BMI and concentrations of lipid, MDA, oxLDL, leptin and PAI-1 decreased significantly in both groups. PON-1 activity increased and was negatively correlated with BMI (r=-0.618, P< 0.01), MDA (r=-0.735, P<0.001), oxLDL (r=-0.701, P< 0.01), leptin (r=-0.626, P<0.01) and PAI-1 (r=-0.461, P<0.05). There was a correlation between BMI and MDA (r=0.790, P <0.001), and also leptin (r=0.900, P<0.001) and PAI-1 (r=0.888, P=0.001). There was no correlation between BMI and oxLDL. Conclusion: These findings support the hypothesis that in morbid obesity, weight loss after surgery has positive effects on fibrinolytic function, oxidative stress and antioxidant activity. Both operative approaches had similar effects in this study.

Total Intravenous Anesthesia versus Single Breath Technique and Anesthesia Maintenance with Sevoflurane for Bariatric Operations

Background: The choice of anesthetic technique for general anesthesia in morbidly obese patients remains controversial. We aimed to compare blood gases, recovery and hemodynamic parameters using TIVA and sevoflurane anesthesia in bariatric surgery. Methods: The study was performed with permission of the ethics committee.We studied 40 morbidly obese patients allocated to 2 groups. The total I.V. anesthesia (TIVA) group was named Group T, and the sevoflurane group was named Group S. In Group T, anesthesia induction was achieved with propofol. In Group S, anesthesia induction was achieved by sevoflurane with single breath technique, with maintenance provided with 1-2% volume sevoflurane. Student t, Chi square and ANOVA tests were used for data analysis; p-value <0.05 was considered statistically significant. Results: There was no significant difference between the 2 groups in demographic data, blood gas values and recovery characteristic. Hemodynamic values were significantly lower in Group T than Group S, during and after the operative period. Conclusion: While sevoflurane induction and maintenance is a suitable anesthetic modality for obese patients, TIVA can be applied easily in those patients possessing no extra risk factors other than morbid obesity.

Detachment of the Connecting Tube from the Port and Migration into Jejunal Wall

After laparoscopic adjustable gastric banding (LAGB), early recognition and treatment of uncommon complications are important. A 36-year-old man who had undergone LAGB presented at our clinic with weight gain of 14 kg during the prior 6 months. During investigation, detachment of the connecting tube from the port and migration of this tube into the jejunal wall were found. The detached port was replaced with a new port, and laparoscopically-assisted jejunorraphy was performed.

Systemic Inflammatory Response after Laparoscopic and Open Application of Adjustable Banding for Morbidly Obese Patients

Background: Surgical injury induces a systemic inflammatory metabolic-endocrine response that is proportional to the severity of the surgical stress. Compared with the conventional open method, laparoscopic surgery is mini-invasive and has decreased postoperative pain and length of hospitalization. The aim of this study was to investigate the systemic inflammatory response, after laparoscopic and open stoma-adjustable silicone band application, which is thought to be mediated by cytokines. Method: 30 morbidly obese patients underwent Swedish adjustable gastric banding (SAGB). 15 patients underwent laparoscopic (group 1) and 15 open SAGB (group 2). Mean operative time for the laparoscopic group was 70-110 min and for the laparotomy group 80-120 min. Gallbladders were not removed,and there were no systemic diseases in the patients.The intensity of surgical trauma was evaluated by measurement of metabolic and hormonal responses to the surgery. Plasma levels of C-reactive (CRP), haptoglobin, ceruloplasmin, albumin, transferrin, IL-6, malonic dialdehyde (MDA) and creatinine were measured before and after the operation. Results: CRP and IL-6 levels increased during and after laparoscopic and open SAGB. However, postoperative responses were significantly greater after open SAGB (group 2) (p<0.05). MDA level, an indicator of an oxidative trauma, was elevated in group 1 at the 6th postoperative hour but was significantly higher in group 2 at the 6th and 12th postoperative hours. The results were more significant in group 2 (p<0.05).There was no statistical difference between groups 1 and 2 in terms of albumin, creatinine, and transferrin levels before and after surgery. Conclusion: The systemic inflammatory res ponses after laparoscopic SAGB were significantly reduced compared with those after open SAGB.

Intraluminal Duodenal Obstruction by a Gastric Band Following Erosion

Background: Duodenal obstruction occurred 4 years following gastric banding for morbid obesity, which had had a good result. Method: A 56-year-old female with a history of gastric banding presented with duodenal obstruction. Result: Physical and radiological examination was able to give the diagnosis. At surgery, the gastric band in the distal duodenum was removed. She was discharged on postoperative day 4, with no complication. At 6 months following discharge, her nausea and vomiting have not recurred. Conclusion: Following gastric banding, band erosion through the gastric wall and internalization into the lumen can cause small bowel obstruction.

The effects of pneumoperitoneum on respiratory mechanics during bariatric surgery.

Background:The aim of this study was to investigate the influence of laparoscopic and conventional open surgery on respiratory mechanics, and blood gases, and to determine convenient techniques from the point of view of intraoperative respiratory mechanics, for bariatric surgery. Method: 40 morbidly obese patients were divided into 2 groups, patients undergoing laparoscopy Group 1, and patients undergoing conventional open surgery Group 2. Resistance of airway, dynamic compliance, and peak inspiratory pressure were measured. Measurement was performed in 4 periods: a) after anesthesia induction, b) after pneumoperitoneum in the Group 1 and after incision in the Group 2, c) after gastric band placement, d) and 5 min before extubation. Blood gases were recorded concomitantly. Results: There was no significant difference between the 2 groups in values of blood gases and respiratory mechanics. Conclusion: In the morbidly obese, laparoscopic and open surgery did not cause a significant difference for respiratory mechanics when compared with each other.

Concomitant Laparoscopic Adjustable Gastric Banding and Laparoscopic Cholecystectomy in a Super-Obese Patient with Situs Inversus Totalis Who Previously Underwent Intragastric Balloon Placement

Laparoscopic adjustable gastric banding has been increasingly performed since its introduction in 1990. Situs inversus totalis is a rare anomaly in which transposition of organs to the opposite side of the body occurs. Laparoscopic gastric banding in such few patients has been reported in the literature. We discuss a super-obese patient with situs inversus totalis and asymptomatic cholelithiasis who previously underwent endoscopic intragastric balloon placement in preparation for bariatric surgery. Afterwards, laparoscopic cholecystectomy and laparoscopic adjustable gastric banding were performed in the same session. Special attention is paid to the literature review and the mirror-image modification of the laparoscopic cholecystectomy and laparoscopic gastric banding procedures. With preoperative assessment, modifications in the surgical team, and equipment, the operation can be performed safely.

Laparoscopy offers diagnosis and treatment in abdominal stab injuries.

Purpose To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). Methods Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. Results From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. Conclusions Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.

Laparoscopy in Turkish Bariatric Surgery: Initial Experience

Background: The recent application of the laparoscopic method combines minimal invasiveness with reversibility, adjustability and shorter hospital stay. The first laparoscopic bariatric operation in Turkey was performed by us in 1998. Methods: We report the results in 50 consecutive patients who underwent the laparoscopic application of SAGB between April 1998 and April 1999.The operation setting was the same as for the laparoscopic antireflux procedure. After a closed CO pneumoperi2 toneum (16-18 mmHg), in the first 20 cases five and in the remaining 30 cases four trocars were inserted. A 30°laparoscope was placed on the line between the umbilicus and the xiphoid through a 10 mm trocar.We followed and respected the main steps of the operation as well. Pre and postoperative body weight (BW), body mass index (BMI) and percent excess weight (%EW) values were calculated and compared. Results: Our early results were quite satisfactory and promising. After an average follow-up period of 1 year (range 6-18 months), the 50 patients of our laparoscopic series showed a BW of 74 kg (range 56- 112), a BMI of 29 (range 21-40), and an EW of 62% (range 22-86). Conclusion: With its lower morbidity rate, shorter hospital stay and better cosmetic results, the laparoscopic approach may be considered the first choice in bariatric surgery.

A new instrument, the "Perfore-Aspirator" for laparoscopic treatment of hydatid cysts of the liver.

The authors introduce a new instrument functioning as both perforator and aspirator in the laparoscopic management of hepatic hydatid cysts. Between January 1998 and January 2002, 11 laparoscopic cystotomy + partial cystectomy + drainage procedures were performed for eight consecutive patients. Eight of the cysts were located in the right lobe, and the remaining three in the left. The average diameter (±SD) of the cysts was 9.6 ± 3.66 cm, and the mean age of the patients was 31.3 ± 7.24 years. The diagnosis was confirmed by ultrasonography and/or computerized tomography. The procedure was performed with the help of three ports. The “perfore-aspirator” instrument (Bahadir Tibbi Aletler A. S., Samsun, Turkey) was introduced through the 10-mm trocar at the subcostal area, and the cystotomy procedure was done with success. Then, a partial cystectomy procedure was performed with the use of a grasper and scissors attached to an electrocautery device. The average hospitalization period was 5 ± 1.69 days. No major morbidity or mortality was seen. All patients were treated with albendazole preoperatively and postoperatively.