Konstantinos M. Stamou

Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results.

BackgroundSleeve gastrectomy involves the creation of small gastric reservoir based on lesser curvature of the stomach, which is fashioned by a longitudinal gastrectomy that preserves the antrum and pylorus together with its vagal innervation. The main complications in the early postoperative course are bleeding and gastric leak. In order to reduce these complications the staple line can be reinforced in many different ways. The purpose of this study was to randomly compare two different techniques in laparoscopic sleeve gastrectomy (LSG): buttressing the staple line at the gastroesophageal junction (angle of Hiss) with Gore Seamguard and staple-line suturing with PDS 2.0.MethodsBetween July 2009 and July 2010, 90 patients were prospectively and randomly enrolled in the two different techniques of handling the staple line during LSG. Forty-eight of these patients belonged in group A (application of Gore Seamguard) and 42 in group B (application of a continuous suture). Operative and postoperative complications were recorded.ResultsPostoperative leak affected two patients in group A (4.2%) and bleeding occurred in one patient of group A (2%). Total complication rate was 6.2% for group A. No major surgical complication occurred in group B. The differences between the two groups did not reach statistical significance.ConclusionsNo significant difference is evidenced in terms of bleeding and postoperative leak between the two techniques of enhancing the staple line in LSG. Suturing of the staple line may be more time consuming but costs are considerably less.

Implantation of microballoons in the management of fecal incontinence.

PURPOSE: The implantation of expandable microballoons has proved successful for the treatment of stress urinary incontinence. This led us to test its effectiveness in the treatment of severe fecal incontinence. METHODS: Six patients (four male), of average age of 43 (range, 29–60) years, with severe fecal incontinence, underwent implantation of expandable microballoons in the submucosa of the anal canal. The implantation was performed under intravenous sedation as an outpatient procedure. Anal manometry, endosonography, and incontinence assessment with a scoring system were performed before and after the implantation. RESULTS: With a mean follow-up of 8.6 (range, 7–12) months, the incontinence scores improved in all patients from an average of 16.16 (standard deviation: ± 1.6) before the implantation to an average of 5 (standard deviation: ± 1.26) after the procedure. The anal pressure at rest was not improved in any patient (mean: 50.16 before treatment to a mean of 53 after treatment). No significant adverse events were associated with the procedure, and no serious postim-plantation complications were noted. DISCUSSION: Anal implantation of expandable microballoons seems to be a simple, safe, and effective method that restores the fecal continence without hindering normal defecation.

Bougie insertion: A common practice with underestimated dangers

INTRODUCTION Esophageal perforation after bariatric operations is rare. We report two cases of esophageal perforation after bariatric operations indicating the dangers of a common practice - like insertion of esophageal tubes - and we describe our management of that complication. PRESENTATION OF CASE A 56 year old woman who underwent laparoscopic sleeve gastrectomy and a 41 year old woman who underwent laparoscopic adjustable gastric banding respectively. In both operations a bougie has been used and led to esophageal perforation. DISCUSSION The insertion of bougie and especially of inflated bougie is a common practice. It is an invasive procedure that in most cases is performed by the anesthesiologist team. CONCLUSION Bougie insertion is an invasive procedure with risks and should always be attempted under direct supervision of surgical team or should be inserted by a surgeon.

Plexiglas (polymethylmethacrylate) implantation: technique, pre-clinical and clinical experience

Over the past few decades, a great scientific effort has been made to treat gastroesophageal reflux disease (GERD). This reflects a trend in modem medicine toward optimizing quality of life, reducing health-related lost working hours, and minimizing costs of chronic treatments. It also reflects a revived interest in diseases that can be studied using novel equipment and that can be cured using minimally invasive techniques. In an effort to further minimize surgical trauma, novel endoscopic techniques are beginning to challenge the standard therapeutic approach to GERD.

The effect of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) as an adjuvant in patients with resectable pancreatic cancer

Abstract Background – aims: The long-term survival of pancreatic cancer is poor even after potentially curative resection. The incidence of local-regional failures is high. There is evidence that hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) is effective in controlling the local-regional failures. The purpose of the study is to identify the effect of HIPEC after surgical removal of pancreatic carcinoma. Patients – Methods: Prospective study including 33 patients with resectable pancreatic carcinomas. All patients underwent surgical resection (R0) and ΗIPEC as an adjuvant. Morbidity and hospital mortality were recorded. The patients were followed-up for 5 years. Survival was calculated. Recurrences and the sites of failure were recorded. Results: The mean age of the patients was 67.8 ± 11.1 years (38–86). The hospital mortality was 6.1% (2 patients) and the morbidity 24.2% (8 patients). The overall 5-year survival was 24%. The mean and median survival was 33 and 13 months, respectively. The median follow-up time was 11 months. The recurrence rate was 60.6% (20 patients). Three patients were recorded with local-regional failures (9.1%) and the others with liver metastases. Conclusions: It appears that HIPEC as an adjuvant following potentially curative resection (R0) of pancreatic carcinoma may effectively control the local-regional disease. Prospective randomised studies are required.

Lack of significant intraoperative coagulopathy in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) indicates that epidural anaesthesia is a safe option

Abstract Purpose: The purpose of this study is to evaluate the fluctuations of coagulation parameters during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) and confirm beyond doubt that epidural anaesthesia is safe with this type of operations. Materials and methods: This is a prospective clinical study of consecutive patients who had cytoreductive surgery and HIPEC. An epidural catheter was inserted into all patients. Peripheral venous blood samples in specific time points of the procedure were tested for complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalised ratio (INR), fibrinogen, D-dimer, and expression of the GpIIb/IIIa platelet receptor. Results: A total of 51 consecutive patients were included in this study. The initial mean (SD) platelet count decreased significantly to a mean of 250.6 (105.4) 109/L (p < 0.001). Fibrinogen levels decreased to 295.9 (127.4) mg/dL (p = 0.009). D-dimer levels increased to 5.3 (3.1) mg/dL (p < 0.001). APTT increased from 30.8 (5.8) s to 35.1 (4.6). The mean INR increased significantly to 1.5 (0.5) (p < 0.001). The total number of GpIIb/IIIa platelet receptors showed no significant variation throughout the measurements and was 72603.2 before HIPEC, 80772.4 during, and 77432.1 after. All the parameters examined, despite significant fluctuations remained in levels that would permit perioperative epidural analgesia. No related complications were recorded. Conclusion: Our results support the belief that epidural analgesia is a safe option in cytoreductive surgery and HIPEC despite certain intraoperative fluctuations in coagulation parameters. It is of major importance to regulate any abnormalities observed during surgery. There are no available data regarding the occurrence of coagulopathy in the post-operative period.

Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature

Abstract Background: Encouraging results on survival of patients with malignant peritoneal mesothelioma have been shown with the use of cytoreductive surgery and perioperative intraperitoneal chemotherapy. This study explores the impact of aggressive surgical treatment on overall survival of peritoneal mesothelioma. Methods: This is a retrospective analysis of prospectively collected clinical data of all patients with diagnosis of malignant peritoneal mesothelioma treated in a designated referral centre in Greece. All patients were offered cytoreductive surgery and intraperitoneal chemotherapy. Patient’s characteristics, operative reports, pathology reports, and discharge summaries were stored in an electronic database and later reviewed and analysed. Results: Cytoreduction for peritoneal mesothelioma was performed on 20 patients (15 men and 5 women) with a mean age of 59.4 years (SD 16.1). Mean peritoneal cancer index was 16.1 (SD 10.4) and the median completeness of cytoreduction score was 2 (range 1–2). Mean overall survival was 46.8 months (SE 4.03) with a mean of 21.4 and median of 18 months of follow-up. Disease-specific survival was 100% for the observed period. Univariate analysis showed the completeness of cytoreduction as the only possible predictor of survival. A median of 10 (range 4–14) peritonectomy procedures were performed per patient. Median hospital stay was 14 (range 10–57 days). Grade III and IV complications occurred post-operatively in 5 patients (25%). Two patients died in the post-operative period of pulmonary embolism and myocardial infarction. Conclusion: Cytoreductive surgery with HIPEC has proved the most effective treatment even when taking account of the cost of significant morbidity.

Modified technique for repairing large incisional hernias.

About 1.7% of all abdominal wall hernias are incisional hernias and they have an expected incidence of 2–5% in uncomplicated abdominal operations which rises to 10%–15% in operations complicated by infection. It is estimated that incisional hernias will complicate 9% of all major abdominal operations and 30% of these hernias show thenselves within the rst 30 postoperative months (1, 5). Risk factors for hernia occurrence are infection and wound dehisence, length of the primary incision, and the use of corticoids during primary operation; in addition, obesity, postoperative cough or high intra-abdominal pressure, and technical errors all predispose to the development of a postoperative incisional hernia (3, 6). Large incisional hernias, apart from physical discomfort and deformity, are the cause of “Eventration Disease” according to Rives (8), which induces multiple symptoms from different systems. Important symptoms derive from pulmonary dysfunction, but symptoms from the gastrointestinal tract, skeletal pain and abdominal skin atrophy are not to be underestimated. Patients operated on for a large abdominal wall hernia face a high incidence of postoperative morbidity, mainly from pulmonary dysfunction, wound infection and the sudden rise in intra-abdominal pressure (10), despite the use of “progressive pneumoperitoneum”, which is a useful technique for preparing patients with large abdominal hernias. Many techniques have been used for repairing these large hernias but recurrence rates remain high, reaching 50% for the Mayo procedure (2, 7). The use of synthetic materials improved the recurrence rates but the results are not yet wholly satisfactory (4). Large incisional hernias pose a challenge in their repair technique and demand a thorough preoperative evaluation of the patient as regards respiratory function, prophylaxis of deep venous thrombosis and infection. Any postoperative complication might jeopardise the outcome. METHODS

Hemodynamic Monitoring During Heated Intraoperative Intraperitoneal Chemotherapy Using the FloTrac/Vigileo System.

Cytoreductive surgery with HIPEC has provided a chance for long-term survival in selected patients. However, perioperative management remains a challenge for the anesthesiology team. The aim of this study was to evaluate the changes in hemodynamic parameters during hyperthermic intraperitoneal chemotherapy (HIPEC) using the FloTrac/Vigileo system. Forty-one consecutive patients undergoing cytoreductive surgery and HIPEC were enrolled. Heart rate (HR), esophageal temperature, and cardiac output (CO) steadily increased until the end of HIPEC. In the first half of HIPEC, systolic blood pressure (SBP) and central venous pressure (CVP) increased whereas systemic vascular resistance (SVR) decreased; SVR stabilized in the second half. Diastolic blood pressure (DBP), mean arterial pressure (MAP), and stroke volume (SV) showed no significant variation. Male gender was related to increased CVP, CO, and SV, and decreased SVR; age >55 years was related to increased SBP, and peritoneal cancer index (PCI) was correlated with HR, DBP, and SV. PCI >14 was associated with increased HR and decreased DBP and MAP. American Society of Anesthesiologists score >1 was related to decreased CO and SV. Patients undergoing HIPEC develop a hyperdynamic circulatory state because of the increased temperature, characterized by a steady decrease in SVR and continuous increase in HR and CO. FloTrac/Vigileo system may provide an easy-to-handle, noninvasive monitoring tool.

Sleeve gastrectomy may not be an appropriate weight loss operation in patients with diffuse idiopathic skeletal hyperostosis

Aim-backgroundDiffuse idiopathic skeletal hyperostosis (DISH) is a common disease among obese patients, though not easily suspected in obesity surgery departments.Case reportWe present the case of a 40-year-old woman with morbid obesity (BMI of 43kgr/m2) and undiagnosed DISH who underwent a laparoscopic sleeve gastrectomy (LSG). Postoperatively, she presented serious dysphagia and failure to lose weight.ResultsThe patient complained of severe dysphagia postoperatively, for solid foods and cooked meals in particular. A gastroscopy and upper gastrointestinal swallow radiographs did not show stenosis. Dysphagia led the patient to a high-calorie low-viscosity diet and inability to lose weight. Two years after the operation, the patient underwent radiography and MRI of the thoracic and lumbar spine due to chronic low back pain; the diagnosis of DISH was set by a rheumatologist.ConclusionPatients with DISH may not be good candidates for restrictive bariatric operations. Patients presenting to morbid obesity surgical departments require a full investigation of all possible underlying causes of obesity, including DISH.