Mikael Victorzon

Linear Stapler Technique May Be Safer than Circular in Gastrojejunal Anastomosis for Laparoscopic Roux-en-Y Gastric Bypass: A Meta-analysis of Comparative Studies

The technique of choice for gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity is controversial. We performed a meta-analysis comparing linear versus circular stapler technique to evaluate this issue. A systematic literature search was performed. Primary outcomes were gastrojejunal leak and stricture. Secondary outcomes were operative time, length of hospital stay, post-operative bleeding, wound infection, marginal ulcers and estimated weight loss. Eight studies involving 1,321 patients were retrieved and included in the present study. A significantly decreased risk of GJ stricture was observed after using linear versus circular stapler (RR, 0.34; 95% CI, 0.12–0.93; p = 0.04). Wound infection risk (RR, 0.38; 95% CI, 0.22–0.67; p = 0.0008) and operative time (MD, −24.18; 95% CI, −35.31, −13.05; p < 0.0001) were significantly reduced by using linear stapling. No significant differences were observed in the other outcome end-points. The use of the linear stapler compared with circular stapler for GJ during LRYGB for morbid obesity may be associated with a reduced risk of anastomosis stricture and wound infection, as well as with a shorter operative time.

Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux

Background: Conflicting results regarding the influence of laparoscopic adjustable gastric banding (LAGB) on gastroesophageal reflux disease (GERD) have been published. Methods: A prospective follow-up study was conducted in 31 patients (male/female 5/26, mean age 44 ± 11 SD years) with 24-hour pH and manometry recordings, symptom assessment, and upper GI endoscopy. Results: Total number of reflux episodes decreased from a mean value of 44.6 ± 23.7 SD preoperatively to 22.9 ± 17.1 postoperatively (P=0.0006), after a median follow-up time of 19 months (range 7-32 months). Total reflux time decreased from 9.5% ± 6.2% to 3.5% ± 3.7%, P=0.0009, and DeMeester score decreased from 38.5 ± 24.9 to 18.6 ± 20.4, P=0.03. Symptomatic patients decreased from 48.4% preoperatively to 16.1% postoperatively (P=0.01), medication for GERD decreased from 35.5% to 12.9% (P=0.05), and the diagnosis of GERD on 24-hour pH recordings decreased from 77.4% to 37.5% (P=0.01). There were no pouch enlargements seen on upper GI endoscopy. Esophageal motility was unchanged, but 36% of the patients had incomplete relaxation of the lower esophageal sphincter following the operation (P<0.0001). Mean BMI decreased from 46.0 ± 5.46 to 38.4 ± 6.45 (P<0.0001), excess weight from 60.0 kg ± 18.58 kg, 44.9% ± 6.56% to 38.4 kg ± 20.27 kg, 28.4% ± 10.97% (P<0.0001). No association between the postoperative diagnosis of GERD and the amount of weight loss could be found. Conclusions: The correctly placed gastric band is an effective anti-reflux barrier in the short term. Long-term results have to be awaited.

Impact of laparoscopic adjustable gastric banding for morbid obesity on disease-specific and health-related quality of life

Background: Health-related quality of life (HRQoL) in Finnish morbidly obese individuals was compared with that of Finnish age norms and prospectively with the HRQoL and the disease-specific quality of life (QoL) at 12 months, and cross-sectionally at 28 months, following laparoscopic adjustable gastric banding, mainly with the Swedish band. Methods: The Moorehead-Ardelt questionnaire was used for disease-specific QoL assessments in 95 patients preoperatively, in 52 patients prospectively followed-up to 12 months, and cross-sectionally in 52 patients operated at a median of 28 months earlier. A generic 15-dimensional questionnaire was used for HRQoL-measurements in 75 patients preoperatively, and 34 patients have been followed-up to 12 months. HRQoL outcomes were compared cross-sectionally with the 52 patients operated at a median of 28 months earlier. Results: Disease-specific QoL scores were significantly improved on all domains of the Moorehead-Ardelt questionnaire 12 months after surgical treatment, an impr ovement maintained at a median of 28 months follow-up. Significant improvements in generic HRQoL scores were seen on the dimensions mobility, respiratory function, sleep, the performance of usual acts, vitality and sexuality 12 months after surgery. Significant worsening was seen on the eating dimension. Of these dimensions, mobility and sleeping were not significantly improved at a median of 28 months follow-up, and scores on the eating dimension were not significantly worse compared with values obtained in the preoperative group. HRQoL single index score was significantly improved 12 months after surgery. This improvement did not correlate with the extent of weight loss. Conclusion: Disease-specific QoL was significantly improved at 12 months follow-up, an improvement that seems to have been maintained at a median of 28 months following operation. HRQol was significantly improved 12 months after the operation. There may be a decline in the improvements after that.

Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy.

BACKGROUND: Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce. OBJECTIVE: The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection. DESIGN: This is a prospective, multicenter, randomized controlled clinical trial. SETTINGS: This study was conducted at 2 university and 3 central Finnish hospitals. PATIENTS: From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined. INTERVENTIONS: In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma. MAIN OUTCOME MEASURES: The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures. RESULTS: Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups. LIMITATIONS: The study was limited by its small size and short follow-up time. CONCLUSIONS: Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.

Bariatric surgery in elderly patients: a systematic review

Controversy exists regarding the effectiveness and safety of bariatric/metabolic surgery in elderly patients. We performed a systematic review on this issue in patients aged 60 years or older. MEDLINE, Cochrane Library, Embase, Scopus, and Google Scholar were searched until August 2015 for studies on outcomes of bariatric surgery in elderly patients. The results were expressed as pooled proportions (%) with 95% confidence intervals. Heterogeneity across the studies was evaluated by the I2 test, and a random-effects model was used. Twenty-six articles encompassing 8,149 patients were pertinent with this issue and included data on bariatric surgery outcomes in elderly population. Fourteen patients died during the 30-day postoperative period, with a pooled mortality of 0.01%. Pooled overall complication rate was 14.7%. At 1-year follow-up, pooled mean excess weight loss was 53.77%, pooled diabetes resolution was 54.5%, and pooled hypertension resolution was 42.5%, while pooled lipid disorder resolution was 41.2%. Outcomes and complication rates of bariatric surgery in patients older than 60 years are comparable to those in a younger population, independent of the type of procedure performed. Patients should not be denied bariatric surgery because of their age alone.

Quality of Life following Laparoscopic Adjustable Gastric Banding – the Swedish Band and the Moorehead-Ardelt Questionnaire

Background: Although weight loss is an important immediate outcome after gastric banding operations, quality of life (QOL) has been shown to be an equally important outcome measure. Methods: From 1996 to May 2002, 125 consecutive patients have been operated laparoscopically for morbid obesity at our institution with the Swedish Adjustable Gastric Band (SAGB). We compared the Moorehead-Ardelt QOL scores of the first 60 patients, operated at a median of 2 years earlier, with a group consisting of the following consecutive 65 patients, who answered the questionnaire preoperatively. Results: The QOL scores among the operated patients were significantly better (P<0.0001, unpaired t-test) on all domains of the Moorehead-Ardelt questionnaire compared to those not yet operated. Conclusions: Laparoscopic banding with the SAGB has been a safe procedure, with satisfactory weight loss and significant improvement in QOL scores 2 years postoperatively.

Intermediate results following laparoscopic adjustable gastric banding for morbid obesity.

Background/Aims: Morbid obesity is a rapidly increasing health risk in most industrialized countries. Unfortunately, conservative treatment methods will fail in the long run in almost 100% of patients. Today, long-lasting success can only be achieved by operative treatments. Laparoscopic gastric banding has the general benefits of minimally invasive techniques is relatively easy to perform and can be reversed or changed to any other operation aiming at weight loss, if necessary. We report here our primary and intermediate outcome of Laparoscopic Adjustable Gastric Banding (LAGB). Methods: Since 1996–2001 we have treated 110 (87 women, 23 men) morbidly obese patients with the Swedish Adjustable Gastric Band (SAGB). Median age (range) of the patients was 42 years (21–64), and preoperative median body mass index (BMI, kg/m2) (range) was 44 (35–66). Most of the patients suffered from obesity related co-morbidities. Results: At a median follow-up of 27 months, mean weight loss was 30 kg, mean excess weight loss (range) 52% (11–108%), and median (range) BMI 34 (24–46). Reoperations due to band slippage (3 patients), band erosion (2 patients), infection (1 patient), and leakage of the band or the filling system (5 patients) have been necessary in 11 (10%) patients so far. Median postoperative hospital stay (range) was 3 days (2–53). There was no mortality. Immediate postoperative morbidity was 9%. More than 50% of the patients had signs of mild erosive gastroesophageal reflux disease during routine endoscopic follow-up 3 years after the operation. Conclusion: Weight loss following LAGB is generally good and complications few, at least in the short term. However, technical problems with the band causes morbidity and reoperations in a number of patients. Despite this fact, we think the LAGB operation is the best ‘first’ operation in the treatment of morbid obesity, although long-term results are not yet available.

Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial

BackgroundLaparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published.Methods/DesignThis is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days.Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years.DiscussionTo the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction.Trial registrationClinicalTrials.gov identifier:NCT01867528. Date of registration May 26th 2013.

Laparoscopic Silicone Adjustable Gastric Band; Initial Experience in Finland

Background: The Swedish adjustable gastric band (SAGB) was introduced in 1985 and rapidly gained popularity.Today more than 21,000 gastric banding procedures have been performed in Europe. The reported results of gastric banding operations are mainly good, although the method is not without controversies and risks. We report here our initial experience with the SAGB. Methods: 60 patients (44 women, 16 men) were treated surgically for morbid obesity between the years 1996 and 1999, with SAGB. Median age of the patients was 44 years (range 21-64) and preoperative median Body Mass Index (BMI, kg/m2) was 45 (range 35-55). 3 patients were operated by an open approach, and the remaining 57 laparoscopically. Results:Operative time was 62-206 minutes (median 97 minutes). Only one operation was converted to open approach (1.8%), due to extensive adhesions. No intraoperative complications occurred. At 1 year follow-up, mean weight loss was 30 kg, mean excess weight loss was 50%, and median BMI was 35. 4 patients have been reoperated so far (6.7%) due to slippage of the band (2 patients), infection of the band (1 patient), and leaking of the filling system (1 patient). Median postoperative hospital stay was 3 days (range 2-53). Mortality was 0%. Immediate postoperative mor- bidity-rate was 12% (7/60), although serious morbidity occurred in only 1 patient (1.7%). Conclusions: Laparoscopically placed adjustable gastric band is a good option for the morbidly obese patient.