Markus von Flüe

Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial.

Background:The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. Objective:In this randomized, prospective, parallel group study, we sought to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) with those of laparoscopic sleeve gastrectomy (LSG) on fasting, and meal-stimulated insulin, glucose, and glucagon-like peptide-1 (GLP-1) levels. Methods:Thirteen patients were randomized to LRYGB and 14 patients to LSG. The mostly nondiabetic patients were evaluated before, and 1 week and 3 months after surgery. A standard test meal was given after an overnight fast, and blood samples were collected before and after food intake in both groups for insulin, GLP-1, glucose, PYY, and ghrelin concentrations. This trial was registered in www.clinicaltrials.gov (NCT00356213) before the first patient was randomized. Results:Body weight and body mass index decreased markedly (P < 0.002) and comparably after either procedure. Excess BMI loss was similar at 3 months (43.3 ± 12.1% vs. 39.4 ± 9.4%, P > 0.36). After surgery, patients had markedly increased postprandial plasma insulin and GLP-1 levels, respectively (P < 0.01) after both of these surgical procedures, which favor improved glucose homeostasis. Compared with LSG, LRYGB patients had early and augmented insulin responses as early as 1-week postoperative; potentially mediating improved early glycemic control. After 3 months, no significant difference was observed with respect to insulin and GLP-1 secretion between the 2 procedures. Conclusion:Both procedures markedly improved glucose homeostasis: insulin, GLP-1, and PYY levels increased similarly after either procedure. Our results do not support the idea that the proximal small intestine mediates the improvement in glucose homeostasis.

Acute and chronic presentation of intestinal nonrotation in adults

Intestinal nonrotation has been recognized as a cause of obstruction in neonates and children and may be complicated by volvulus and intestinal necrosis. It is very rarely seen in the adult and may present acutely as a bowel obstruction and intestinal ischemia associated with midgut or ileocecal volvulus, or chronically as vague intermittent abdominal pain. The purpose of this communication is to reveal the pathogenesis and the surgical significance of intestinal nonrotation in adults and to review the English and German language literature since 1923 to establish the optimal therapeutic management. Between 1983 and 1992, we have managed and observed prospectively 10 adults with intestinal nonrotation. In four patients the nonrotation has been detected at emergency laparotomy owing to midgut or ileocecal volvulus. Four patients suffered from chronic symptoms of intermittent volvulus or small bowel obstruction and in two patients the nonrotation has been noted as an incidental finding at laparotomy for another condition. A survey of the literature from 1923 to 1992 revealed 40 adults with symptomatic intestinal nonrotation to which we contribute nine patients. We establish that in the acute symptomatic pattern, only emergency laparotomy can provide the correct diagnosis and decrease the risk of bowel disturbance. In the chronic situation, barium studies of the upper and lower gastrointestinal tract reveal varying degrees of midgut malrotation and confirm the nonrotation in each case. Also, in these forms the explorative laparotomy with a consequent staging of the abdominal situs is to be recommended. All reported cases at our institutions are without complaints after surgery. Adult patients with intestinal nonrotation and acute or chronic obstructive symptoms or those detected incidentally at laparotomy for other conditions should undergo a Ladd procedure because of the risk of midgut volvulus. In this operation, the nonrotation is left in place and the ascending colon is sutured at the colon descendens and sigmoideum. After this procedure the mesenteric pedicle is fixed and the risk of midgut torsion remains minimal.

Predictors of outcome in treatment of morbid obesity by laparoscopic adjustable gastric banding: results of a prospective study of 380 patients

BACKGROUND We investigated the outcome predictors of laparoscopic gastric banding (LAGB) for morbidly obese patients. METHODS From December 1996 to November 2004, a total of 380 consecutive unselected patients (78% female; median age 40 yr, range 17-66; body mass index 44.3 kg/m(2), range 35-75) were prospectively evaluated and underwent LAGB. The follow-up rate after a median of 5 years (range 1.5-9.4) was 98%. A survival model was applied, and a multivariate Cox proportional hazard model was used to calculate the hazard ratios for the influential factors. RESULTS Of the 380 patients, 128 (33.7%) had their bands removed. Of these 128 patients, 2.4% declined another operation, 18.2% underwent biliopancreatic diversion with duodenal switch, 7.1% underwent laparoscopic Roux-en-Y gastric bypass, and 6% underwent laparoscopic sleeve gastrectomy. The excess weight loss of the remaining 252 patients (66.3%) with a band in situ (including 21 patients after rebanding) was 40%, and only 25% reached an excess weight loss >50%. Older age, binge eating disorder, and sweet-eating behavior were predictors of a poor outcome after LAGB. In contrast, sex, primary body mass index, and co-morbidities had no influence on outcome. CONCLUSION LAGB was less successful in older patients and in patients with binge eating disorder or sweet-eating behavior. These patients might be candidates for a different bariatric procedure.

New technique for pouch-anal reconstruction after total mesorectal excision

PURPOSE: Surgical options in metachronous or recurrent rectal cancer after anterior or low anterior resection are limited and frequently result in abdominoperineal rectal extirpation sacrificing the sphincter or in straight coloanal reconstruction. Decreased capacity and distensibility in straight coloanal reconstruction after proctectomy correlate well with increased daily stool frequency, urgency, and incontinence. A new technique for coloanal pouch reconstruction using the ileocecal segment is proposed. METHODS: A pedunculated ileocecal segment was rotated 180° counterclockwise and placed between the sigmoid colon and anal canal. Ileal end of the pouch was then anastomosed end-to-end with the transected sigmoid colon and proximal end of the ileum with distal end of the ascending colon. Functional results and defecation quality of a 67-year-old woman are described 6 and 12 months after ileocolonic interposition pouch replacing the tumorbearing rectum. RESULTS: Twelve months postoperatively, the patient is free of disease with an excellent defecation quality, has full anal continence without soiling, is having two solid stools in 24 hours. Functional control revealed normal anal sphincter pressure and large rectal capacity and compliance. Neither outlet obstruction nor incomplete evacuation have been observed. CONCLUSION: The ileocecal interposition pouch (cecum pouch) represents an alternative technique for coloanal reconstruction in low rectal cancer, recurrent rectal cancer, or metachronous low rectal cancer with intact sphincter function. This new method presents some attractive features compared with techniques presently in use.

Ferguson Hemorrhoidectomy: Long-Term Results and Patient Satisfaction After Ferguson’s Hemorrhoidectomy

PURPOSEPerioperative morbidity and long-term results after hemorrhoidectomy (Ferguson’s technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy.METHODSAll records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients.RESULTSFive-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22–96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1–7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases.CONCLUSIONFerguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.

Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infections : a prospective randomized trial

Objective:To assess whether antibiotic prophylaxis at urinary catheter removal reduces the rate of urinary tract infections. Summary of Background Data:Urinary tract infections are among the most common nosocomial infections. Antibiotic prophylaxis at urinary catheter removal is used as a measure to prevent them, albeit without supporting evidence. Methods:A prospective randomized study enrolled 239 patients undergoing elective abdominal surgery, who were randomized either for receiving 3 doses of trimethoprim-sulfamethoxazole at urinary catheter removal, or not. Urinary tract infections were diagnosed according to Center of Disease Control definitions. Urinary cultures were obtained before and 3 days after catheter removal. Subjective symptoms were assessed by an independent study-blind urologist. Results:Patients who received antibiotic prophylaxis showed significantly fewer urinary tract infections (5/103, 4.9%) than those without prophylaxis (22/102, 21.6%), P < 0.001. The absolute risk reduction for the occurrence of a urinary tract infection was 16.7%; the relative risk reduction was 77.5%, and the number needed to treat was 6. Patients with antibiotic prophylaxis also had less significant bacteriuria 3 days after catheter removal (17/103, 16.5%) than those without (42/102, 41.2%), P < 0.001. Conclusions:Antibiotic prophylaxis with trimethoprim-sulfamethoxazole on urinary catheter removal significantly reduces the rate of symptomatic urinary tract infections and bacteriuria in patients undergoing abdominal surgery with perioperative transurethral urinary catheters.

Mitochondrial DNA content in human omental adipose tissue

BackgroundImpairment of mitochondrial function plays an important role in obesity and the development of insulin resistance. The aim of this project was to investigate the mitochondrial DNA copy number in human omental adipose tissue with respect to obesity.MethodsThe mitochondrial DNA (mtDNA) content per single adipocyte derived from abdominal omental adipose tissue was determined by quantitative RT-PCR in a group of 75 patients, consisting of obese and morbidly obese subjects, as well as non-obese controls. Additionally, basal metabolic rate and fat oxidation rate were recorded and expressed as total values or per kilogram fat mass.ResultsMtDNA content is associated with obesity. Higher body mass index (BMI) resulted in a significantly elevated mtDNA count (ratio = 1.56; p = 0.0331) comparing non-obese (BMI < 30) to obese volunteers (BMI ≥ 30). The mtDNA count per cell was not correlated with age or gender. Diabetic patients showed a trend toward reduced mtDNA content. A seasonal change in mtDNA copy number could not be identified. In addition, a substudy investigating the basal metabolic rate and the fasting fat oxidation did not reveal any associations to the mtDNA count.ConclusionsThe mtDNA content per cell of omental adipose tissue did not correlate with various clinical parameters but tended to be reduced in patients with diabetes, which may partly explain the impairment of mitochondrial function observed in insulin resistance. Furthermore, the mtDNA content was significantly increased in patients suffering from obesity (BMI above 30). This might reflect a compensatory response to the development of obesity, which is associated with impairment of mitochondrial function.

Clinical outcome and quality of life after gastric and distal esophagus replacement with an ileocolon interposition.

Mainly because of the loss of reservoir function, loss of sphincter function, and exclusion of the duodenal route, patients who undergo gastrectomy suffer from many adverse effects postoperatively. The ileocecal interpositional graft is an attractive method to use as a gastric substitute after gastrectomy and distal esophagectomy. A pedunculated ileocecal graft is placed between the esophagus and the duodenum. The cecum acts as a reservoir while the ileocecal valve protects against enteroesophageal reflux. The duodenal passage is also preserved. Fourteen patients underwent this operation. The technique-related morbidity was low and the quality of life was good. During a mean follow-up of 6 months, no evidence of severe dumping syndrome or reflux esophagitis was observed. Further prospective randomized studies are warranted to compare this technique with the standard methods of gastric reconstruction.

The ileocecal reservoir for rectal replacement in complicated radiation proctitis

BACKGROUND/AIMS Total rectal resection is the radical treatment method for radiation proctitis complications. Parks straight colo-anal reconstruction to replace the rectum often impairs anal continence, increases stool frequency, and causes imperative urgency. We developed and assessed a colo-anal reconstruction (ileocecal reservoir) after resection of radiation-damaged rectum. METHODS An ileocecal segment was isolated on its lymphovascular pedicel, rotated counterclockwise, and reanastomosed at the dentate line. This provided a neorectal segment with intact intrinsic and extrinsic nerve and lymphovascular supply. We evaluated the safety, defecation quality, and anorectal function of this neorectum in two radiation-injured patients when compared with 15 patients after total mesorectal excision without radiation damage. RESULTS No perioperative morbidity related to this technique was observed. Neorectal patients showed good defecation quality with maximal tolerable volumes, compliances, and anal manometry comparable with patients without radiation injury. CONCLUSIONS This rectal replacement technique permits good defecation quality and excellent anorectal function.

Clinical and histopathological correlations of fecal calprotectin release in colorectal carcinoma

AIM To determine calprotectin release before and after colorectal cancer operation and compare it to tumor and histopathological parameters. METHODS The study was performed on patients with diagnosed colorectal cancer admitted for operation. Calprotectin was measured in a single stool sample before and three months after the operation using an enzyme-linked immunosorbent assay (ELISA). Calprotectin levels greater than or equal to 50 μg/g were considered positive. The compliance for collecting stool samples was assessed and the value of calprotectin was correlated to tumor and histopathological parameters of intra- and peri-tumoral inflammation. Surgical specimens were fixed in neutral buffered formalin and stained with hematoxylin and eosin. Staging was performed according to the Dukes classification system and the 7(th) edition tumor node metastasis classification system. Intra- and peri-tumoral inflammation was graded according to the Klintrup criteria. Immunohistochemical quantification was performed for MPO, CD45R0, TIA-1, CD3, CD4, CD8, CD57, and granzyme B. Statistical significance was measured using Wilcoxon signed rank test, Kruskal Wallis test and Spearmans rank correlation coefficient as appropriate. RESULTS Between March 2009 and May 2011, 80 patients with colorectal cancer (46 men and 34 women, with mean age of 71 ± 11.7 years old) were enrolled in the study. Twenty-six patients had rectal carcinoma, 29 had left-side tumors, 23 had right-side tumors, and 2 had bilateral carcinoma. In total, 71.2% of the patients had increased levels of calprotectin before the operation (median 205 μg/g, range 50-2405 μg/g) and experienced a significant decrease three months after the operation (46 μg/g, range 10-384 μg/g, P < 0001). The compliance for collecting stool samples was 89.5%. Patients with T3 and T4 tumors had significantly higher values than those with T1 and T2 cancers (P = 0.022). For all other tumor parameters (N, M, G, L, V, Pn) and location, no significant difference in calprotectin concentration was found. Furthermore, the calprotectin levels and histological grading of both peri- and intra-tumoral inflammation was not correlated. Additional testing with specific markers for lymphocytes and neutrophils also revealed no statistically significant correlation. CONCLUSION Fecal calprotectin decreases significantly after colorectal cancer operation. Its value depends exclusively on the individual T-stage, but not on other tumor or histopathological parameters.