Maciej Michalik

Comparison of percentage excess weight loss after laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding.

Introduction Laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) are acceptable options for primary bariatric procedures in patients with body mass index (BMI) 35–55 kg/m2. Aim The aim of this study is to compare the effects of these two bariatric procedures 6, 12 and 24 months after surgery. Material and methods Two hundred and two patients were included 72 LSG and 130 LAGB patients. The average age was 38.8 ±11.9 and 39.4 ±10.4 years in LSG and LAGB groups, with initial BMI of 44.1 kg/m2 and 45.2 kg/m2, p = NS. Results The mean percentage of excess weight loss (%EWL) at 6 months for LSG vs. LAGB was 36.3% vs. 30.1% (p = 0.01) and at 12 months was 43.8% vs. 34.6% (p = 0.005). The greatest difference in the mean %EWL at 12 months was observed in patients with initial BMI of 40–49.9 kg/m2 in favor of LSG (47.5% vs. 35.6%; p = 0.01). Two years after surgery there was no advantage of LSG and in the subgroup of patients with BMI 50–55 kg/m2 there was a trend in favor of LAGB (57.2% vs. 30%; p = 0.07). The multiple regression model of independent variables (age, gender, initial BMI and the presence of comorbidities) proved insignificant in prediction of the best outcome in means of %EWL for either operative modality. None of these factors in the logistic regression model could determine the type of surgery that should be used in particular patients. Conclusions During the first 2 years after surgery, the best results were obtained in women with lower BMI undergoing LSG surgery. The LSG provides greater %EWL after a shorter period of time though the difference decreases in time.

Transanal endoscopic microsurgery via TriPort Access System with no general anesthesia and without sphincter damage.

The aim of this study was to develop a less-invasive transanal endoscopic microsurgery (TEM) operative technique that could be applied in severely ill patients. Modified technique of TEM operation with use of the TriPort Access System in place of the operative rectoscope was designed. Harmonic scalpel and regular laparoscopic instruments were used. Resection of the rectal stump tumor was performed. A 71-year-old male patient with recurrent adenocarcinoma T2N0M0 in rectal stump and ASA 4 was operated using presented technique with good outcome. Total operating time was 25 minutes. There were no adverse events during or after the procedure. Patient was fully mobilized directly after the procedure. Proposed technique can be performed in severely ill patients as it avoids anal sphincter divulsion and therefore general anesthesia. Standard laparoscopic instruments can be used at no extra cost and no need for additional skills.

Long-term outcomes of stapled hemorrhoidopexy

Introduction Hemorrhoidal disease is one of the commonest anorectal disorders worldwide. Stapled hemorrhoidopexy (SH) is a treatment modality associated with low postoperative pain and early mobilization. Aim To assess long-term outcomes after SH. Material and methods All 326 patients who underwent SH in 1999–2003 were invited by mail to participate. For each patient we analyzed their medical records, and conducted a questionnaire survey and a digital rectal examination. Results Only 91 patients attended the final examination and the mean ± SD follow-up time was 8.7 ±1.2 years. Recurrences were diagnosed in one third of the 91 subjects. There were correlations between recurrences and: the duration of disease (p = 0.047); female gender (p = 0.037); and childbirth (vaginal delivery) (p = 0.026). Sixty-seven patients (73.6%) were satisfied with the outcomes. In the group of dissatisfied patients symptoms such as pain (p = 0.0001), burning (p = 0.0002) and itching (p = 0.014) were most common. Long-term outcomes were good with 75% and 88% reductions in pain sensation and severe and moderate hemorrhoidal bleeding. Pruritus, burning and discomfort resolved in more than 50% of patients. Flatus incontinence, fecal incontinence, or soiling occurred in 21%, 11%, and 32% of patients. Conclusions Long-term results of stapled hemorrhoidopexy are satisfactory in most patients. The 36% recurrence rate correlates with the degree of hemorrhoidal prolapse before the operation, duration of the disease, female gender, and previous vaginal delivery.

Transumbilical laparoendoscopic single-site total mesorectal excision for rectal carcinoma.

In recent years, multiple studies have proved laparoscopic total mesorectal excision (TME) to be as safe and as effective in rectal cancer treatment as open surgery, with the undeniable benefit of perioperative trauma reduction. Decreasing the number of incisions and performing single-port surgery could have further reduced the trauma. A new access device, QuadPort™ Olympus, enables operations from just one small transumbilical incision, leaving a barely visible scar afterwards. This is one of the first reports of transumbilical laparoendoscopic single-site TME for rectal carcinoma. A 73-year-old woman presented with tubulo-villous adenoma with high-grade dysplasia and focal adenocarcinoma in situ at 7 cm from the anal verge. She had TME performed via a QuadPort™, Olympus, in line with principles of laparoscopic TME. The operating time was 80 min. There were no adverse events during the procedure. Total blood loss was less than 100 ml. There were no complications in the postoperative period. The patient required only non-opioid analgesia, during the first 2 days. The patient was discharged on the 3rd postoperative day with standard recommendations. Feasibility and safety of the proposed transumbilical laparoendoscopic single site TME for rectal carcinoma was proved. It is a technically demanding procedure, requiring appropriate laparoscopic skills. The QuadPort provided good oncological protection of the wound and easy specimen extraction. Reduced operative trauma resulted in no opioid administration in the perioperative period. Hospital stay was comparable with laparoscopic TME but the cosmetic effect was much better.

Surgery of the elderly in emergency room mode. Is there a place for laparoscopy

Introduction An important yet difficult problem is qualification for surgery in elderly patients. With age the risk of comorbidities increases – multi-disease syndrome. Elderly patients suffer from frailty syndrome. Many body functions become impaired. All these factors make the elderly patient a major challenge for surgical treatment. Aim Analysis of the possibility of developing the indications and contraindications and the criteria for surgical treatment of the elderly based on our own cases. Discussion whether there is a place for laparoscopy during surgery of the elderly in emergency room (ER) mode. Material and methods The analysis was performed based on seven cases involving surgical treatment of elderly patients who were admitted to the hospital in emergency room mode. The patients were hospitalized in the General and Minimally Invasive Surgery Clinic in Olsztyn in 2016. Results Surgical treatment of elderly patients should be planned with multidisciplinary teams. Geriatric surgery centers should be developed to minimize the risk of overzealous treatment and potential complications. Laparoscopy should always be considered in the case of ER procedures or diagnostics. Conclusions Elderly patients should not be treated as typical adults, but as a separate group of patients requiring special treatment. Due to the existing additional disease in the elderly, the frailty syndrome, any surgical intervention should be minimally invasive. The discussion about therapy should be conducted by a team of specialists from a variety of medical fields.

A numerical scale to assess the outcomes of metabolic/bariatric surgery (NOMS)

Introduction Absent today is a simple numerical system of outcomes assessment that recognizes that bariatric surgery is metabolic surgery and incorporates weight loss, hypertension control, and type 2 diabetes control. Aim To introduce a simple, new Numerical Scale to Assess the Outcomes of Metabolic Surgery (NOMS). Material and methods For the stratification of weight outcomes, we used the percentage excess weight loss (%EWL); for hypertension, the systolic blood pressure (SBP) and diastolic blood pressure (DBP) combined with medication usage; and for type 2 diabetes, the hemoglobin A1c (HbA1c) value combined with medication usage. Results Utilizing the guidelines of the American Diabetes Association, the Working Group of the European Society of Hypertension, the European Society of Cardiology, and the American College of Cardiology/American Heart Association, we propose for %EWL: W1 ≥ 50, W2 > 25 and < 50, and W3 ≤ 25; for hypertension H1 SBP/DPB < 140/90 mm Hg on no medication, H2 SBP/DBP ≥ 140/90 mm Hg with improvement of SBP or possible reduction of antihypertensive medication, and H3 no change or SBP higher than before surgery; for diabetes mellitus D1 HbA1c ≤ 7% and no medication, D2 HbA1c > 7% with a decrease of the HbA1c level or possible reduction of medication, D3 no change in HbA1c or HbA1c higher than before surgery. Designations of H0 and D0 are given if hypertension or diabetes was not present before surgery. Patient examples for numerical scores are provided. Conclusions The introduction of our numerical scale (NOMS) can be of benefit in metabolic/bariatric outcomes assessment; communications among metabolic/bariatric surgery centers, physicians, and patients; and for more precise reporting in the evidence-based literature.

Band misplacement: a rare complication of laparoscopic adjustable gastric banding

Introduction Laparoscopic adjustable gastric banding (LAGB) is considered to be a very effective minimally invasive procedure for treating morbidly obese patients. Nevertheless, there are numerous complications that a good surgeon should be aware of. Most of them have been widely presented in the literature. Aim In this study we would like to focus on the rare but important complication which is ante-gastric positioning of the band. Material and methods Between January 2005 and May 2008, 122 patients (88 female and 34 male) with mean body mass index (BMI) of 48.5 kg/m2 (range 35-80 kg/m2) underwent LAGB procedure. The average time of hospitalization was 2.47 days. The first radiological control with band calibration was performed 6 weeks after the operation. Consecutive follow-up depended on the percent excess weight loss (EWL%). Results Of the 122 patients, 4 (3.3%) presented herein had a band misplaced in the ante-gastric position. There were three out of five surgeons who faced complications of this type. The most and the least experienced team members avoided misplacing the band. Two physicians encountered it at the beginning of their learning curve, and for one it was not related to the process of education. Among other postoperative complications there were two incidents of band slippage, 2 patients had their port localization corrected and in one case drain disconnection occurred. There were no mortalities. Conclusions Ante-gastric positioning of the band was the most common cause of obesity surgery failure in our group of patients. It was very difficult to recognize during the typical postoperative checkups; hence there arose a question whether it has been disregarded in other studies.

Study of the prevalence of gastroesophageal reflux symptoms and the role of each in relation to the GERD Impact Scale, based on a population of patients admitted for laparoscopic surgery compared to a control group

Introduction Gastroesophageal reflux disease (GERD), demonstrated to impair quality of life (QoL), appears to show significant variation in its prevalence. Estimation of the prevalence is difficult. When defined as at least weekly heartburn and/or acid regurgitation, the prevalence reported in Asia is 2.5–27.6%, in Europe 23.7% and in the US 28.8%. Aim The study evaluates the prevalence of GERD symptoms in the assessment of the GERD Impact Scale (GERD-IS) in two age groups of patients. Material and methods Evaluation of the prevalence of GERD symptoms with the GERD Impact Scale survey in two groups of patients: younger and older. A total of 2,649 surveys were rated. Statistical analysis was performed using the data analysis software system Statistica version 10.0 and Microsoft Excel. Results According to this study the symptoms of GERD included in GERD-IS in northern Poland vary from 0.9–2.4% as daily sensations to 18.9–40.5% occurring sometimes. Individuals with hiatal hernia (HH) were significantly older than those without HH. HH was significantly more frequent in males than females. Conclusions Estimation of the prevalence of GERD is difficult, because the medications are widely available and people use them without any consultation. They do not recognize the symptoms as a disease whose treatment can also be surgical. Our analysis shows that the prevalence of symptoms of GERD in northern Poland is as high as 5%. Hence further investigation should be performed and people’s awareness should be raised.

Emergency surgery in older patients

Introduction At present, emergency guidelines do not differentiate between younger adults and older persons. The changing socioeconomic situation associated with the aging population will be challenging for the healthcare system and requires new medical guidelines to best accommodate it. Aim To analyze whether the age and comorbidities of a patient affect acute care surgical outcomes. Material and methods We performed a retrospective study of 161 patients who were admitted in emergency to the Department of General, Minimally Invasive and Elderly Surgery in Olsztyn between May and October 2017. Patients were divided into three age groups. Outcomes in patients older than 80 years were compared with corresponding statistical predictions of morbidity and mortality, as calculated using the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM). Results Patients in the 80+ age group had a higher mortality rate in comparison with those in the other age groups, and a higher number of comorbidities (p = 0.002 and p = 0.001, respectively). The POSSUM morbidity and mortality rates were significantly higher for the older patients who died than for the older patients who were discharged (p = 0.013 and p = 0.003, respectively). Conclusions Decisions about suitable therapy in the acute care setting should be made after consideration of the overall health of a patient. This study shows that age itself has a huge impact on postoperative results. The older the patient is, the higher the risk of perioperative death. We recommend patient evaluation using the POSSUM scale to better predict this risk.

Recommendations for the standards of equipping of the Bariatric and Metabolic Surgery Center.

INTRODUCTION The prevalence of obesity in Poland and worldwide is constantly rising. High effectiveness of bariatric surgery has been proven in literature. It is recommended that bariatric procedures should be done by highly qualified surgeons with the appropriate, up-to-date medical equipment. AIM The purpose of the study is to establish Polish recommendations and standards for the use of medical equipment for bariatric surgery centers. MATERIALS AND METHODS The review of the present recommendations of the worldwide organizations and societies (including EAES, IFSO, SAGES) and guidelines was made. On the basis of current literature and authorss clinical experience we proposed standardized protocol for bariatric surgical equipment. CONCLUSIONS Relevant equipping of bariatric surgery centers and implementation of standardized perioperative and surgery protocols will result in significant improvements in bariatric treatment. This will ensure patients safety, a shorter length of hospital stay and considerably reduce the risk of morbidity. Moreover, it will contribute to the efficacy of the bariatric and metabolic surgery procedures, in accordance with the highest globally accepted standards.