Mojmir Kasalicky

Serum concentrations and tissue expression of a novel endocrine regulator fibroblast growth factor-21 in patients with type 2 diabetes and obesity.

Objectiveu2002 Fibroblast growth factor‐21 (FGF21) is a novel endocrine and paracrine regulator of metabolic homeostasis. The aim of our study was to measure its serum concentrations in patients with obesity, obesity and type 2 diabetes mellitus (T2DM) and healthy subjects (C), and to assess the changes of its circulating levels and mRNA expression after dietary and pharmacological interventions.

Laparoscopic sleeve gastrectomy without an over-sewing of the staple line.

BackgroundIn the past few years, laparoscopic sleeve gastrectomy (LSG) became a widely used bariatric method. Based on results of recent LSG studies, LSG is being increasingly used even as a single bariatric method. On contrary with some other reports, we do not reinforce the LSG staple line with over-sewing. Our pilot study presents treatment outcomes and results 18xa0months after LSG.MethodsSixty-one consecutive morbidly obese (MO) patients (19 male and 42 female) who underwent LSG from January 2006 to May 2008 were included into the study. The mean age, height, and weight were 37.3xa0years (29–57), 168xa0cm (151–187), and 118xa0kg (97–181), respectively, while mean body mass index (BMI) was 41.8 (36.1–60.4). LSG started at 6xa0cm from pylorus and ended at the angle of Hiss. For gastric sleeve calibration 38F, intragastric tube was used. All 61 LSG were performed without over-sewing of the staple line. In the last 24 cases, the staple line was covered with Surgicel™ strips, which were however placed without any fixation to the underlying gastric tissue.ResultsMean operating time was 105xa0min (80–170) and no conversion to open surgery. An 18-month follow-up was recorded in 39 MO patients. The mean weight loss was 31.3 (range, 21–67xa0kg) and mean % excess BMI loss reached 72% (range, 64–97%). Neither leak nor disruptions of the staple line and/or sleeve dilatation were recorded.ConclusionLSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience.

Assessment of the Outcome of Laparoscopic Nonadjustable Gastric Banding and Stoma Adjustable Gastric Banding: Surgeon's and Patient's View

Background: The results of nonadjustable gastric banding (NAGB) and stoma adjustable gastric banding (SAGB) in the treatment of morbid obesity are compared. Of 300 patients operated laparoscopically with NAGB since 1993 and of 25 with SAGB since 1994, 65 in the NAGB and 11 in the SAGB group were available for a 3-year follow-up study. Methods: For assessment of the outcome of our laparoscopic approach in terms of weight loss, length of hospitalization, immediate and late postoperative wound complications, postoperative changes in the band and pouch area, were compared in patients from both groups. The patients opinion on the outcome of the operation and the quality of postoperative digestion was recorded. Results: There was no significant difference in the length of hospital stay and wound complication rate in the two groups or the weight loss at 36 months after surgery. There was a statistically significant lower incidence of postoperative food intolerance and vomiting and a lower rate of immediate and long-term reoperation rate in the SAGB group. Conclusion: SAGB is a method with less postoperative complications in food intolerance and vomiting in comparison with NAGB.

Radical resection of the pyloric antrum and its effect on gastric emptying after sleeve gastrectomy.

BackgroundThe surgical technique of laparoscopic sleeve gastrectomy (LSG) has not been fully standardized yet and there is the unresolved question of what is the optimum size of retained pyloric antrum. The aim of our research was to prove that even after a radical resection of the pyloric antrum the physiological stomach evacuation function can still be preserved.MethodsOur study was based on 12 patients, who were randomly divided into two groups. Patients undergoing radical antrum resection (RA group) underwent gastric emptying scintigraphy to determine the evacuation half-time (T1/2) and food retention in the 90th minute of the test (%GE) both before the operation and 3xa0months afterward. Patients in whom the antrum was preserved (PA group) served as a control group for comparison of postoperative weight loss (in kilogram), decrease in body mass index (BMI), and decline in excess weight (%EWL). The resulting changes were statistically processed.ResultsIn the RA group, the average time T1/2 declined from 57.5 to 32.25xa0min (pu2009=u20090.016) and average retention %GE dropped from 20.5 to 9.5xa0% (pu2009=u20090.073). Differences in the average values of weight, BMI, or %EWL between both groups were of no statistical significance (pu2009>u20090.8).ConclusionsIn the RA group, an increase in gastric emptying postoperatively was noted. Complications such as failure of stomach evacuation were not observed in the RA group. Our results suggest that even more radical resection of the pyloric antrum performed by LSG is possible without concerns of postoperative disorder of the stomach evacuation function.

The Role of Laparoscopy in the Treatment of Morbid Obesity

Background: Laparoscopic surgery was established as a regular surgical technique 11 years ago. There are still some controversies among surgeons about the benefits of this method. Method: A retrospective 3-year analysis of immediate and long-term complication rates, hospitalization length, and weight loss following laparotomic and laparoscopic nonadjustable gastric banding in 150 and 145 patients, respectively, was undertaken. Some of the criteria usually used for comparison of results in laparotomy and laparoscopy in general surgery were used in this analysis as background for the comparison of the two groups of obese patients. One example of the different results of the laparotomic and laparoscopic approaches in bariatric surgery was provided by obese monozygotic twins who underwent surgery the same day in our department, one by laparotomy and the other by laparoscopy. There was a significant difference in hospitalization length, in required postoperative analgesia, and in levels of c-reactive protein. Results: There was no statistical difference in intraoperative complication rates in the two groups, but there was a significant difference in immediate and long-term postoperative complications of wound discharge and incisional hernias. The obese twins illustrate the significant difference in postoperative c-reactive protein levels and in length of operating time and hospitalization in favor of laparoscopy, and this difference supports our results in much larger groups of genetically unrelated patients who were studied. Conclusion: At the end of the 10-year period of laparoscopic surgery for bariatric procedures, the results were impressive. The laparoscopic approach to surgery for morbid obesity was of considerable value in terms of low morbidity and mortality.

Some Complications After Laparoscopic Nonadjustable Gastric Banding

Background: Bariatric surgery is the only currently available, effective, long-term method for controlling morbid obesity. Gastric banding as one of the possible surgical treatments was repeatedly described during the last 10 years. It is a reversible surgical procedure which is primarily performed laparoscopically. Methods: From 1993 to 1998 at the 1st Surgical Department Faculty General Hospital Charles University in Prague we performed nonadjustable gastric banding laparoscopically in 487 patients with morbid obesity (body mass index [BMI] 34 to 49 kg/m2). There were 429 females and 58 males in this group. Results: In 487 patients who underwent laparoscopic nonadjustable gastric banding (LNGB): early postoperative complications occurred in 29 cases (5.9%)--swelling of the gastric mucosa at the site of the nonadjustable band. In three cases (0.6%)--gastric perforations, and in two patients (0.4%)-- bleeding from gastric ulceration at the site of the band. Swelling was treated conservatively with a nasogastric tube and antisecretory and antiedematic drugs. Bleeding was treated by gastrofibroscopy and gastric perforation by open suture of the lesion. Late complications after LNGB occurred in eight patients (1.7%)--gastritis or esophagitis (but at the site of the band in only two patients [0.4%]), and in 13 patients (2.7%)--small upper pouch dilatation. In 24 cases (4.9%), we discovered slippage of the anterior stomach wall above the band. In three patients (0.6%), the band migrated through the gastric wall in 6-12 months following surgery. In the majority of cases, treatment of these complications was conservative. In eight patients we removed the band by laparoscopy, and in three patients we removed the migrating band from the stomach by open gastrotomy. Other complications have been treated conservatively by correcting the diet, prokinetic drugs, and antisecretory treatment. Conclusions: According to our long-term results, LNGB by experienced bariatric and laparoscopic surgeons is a viable method with low morbidity. In our 487 patients, there were major complications (necessitating reoperation) in 3.2% and minor complications (treated conservatively) in 10.4%.

Influence of some hereditary factors on weight loss following conservative and surgical treatment of obese female monozygotic twins.

Background: The important role of hereditary factors in the etiology of obesity has been demonstrated by various authors in last few years. The possible influence of some genetic factors on weight reduction or maintenance following conservative and/or surgical treatment was studied in 14 pairs of obese female monozygotic twins. Methods: 12 pairs of twins underwent a weight reduction regimen initiated by short-term inpatient treatment; two pairs were treated by nonadjustable gastric banding. Some factors that may be genetically influenced and that can predict, to some extent, success or failure in long-term weight loss were followed up in obese pairs. Results: The most valuable predictors of long-term outcome in this group of patients were initial weight loss, fat mass, respiratory quotient, waist circumference, and sagittal abdominal diameter. Conclusion: Hereditary factors cause significantly higher risk of treatment failure in some obese subjects. There is a need to pay special attention to these factors in order to achieve successful long-term weight loss.

Comparison of SAGB QC "Classic" Titanium Port and Velocity™ Port: Pilot Phase Prospective Randomized Study on Perioperative and Short-term Postoperative Implantation Outcomes

Background: Port implantation in adjustable gastric banding (AGB) is usually considered as the least compelling, however, it is one of the very important parts of the operation. Port placement can take up to 10% of the overall AGB operating time, and inadequate technique can result in complications in the short- and long-term postoperative period (port torsion, infection, protrusion, port-site persistent pain, etc). Methods: From Dec 2005 - Feb 2006, 40 consecutive patients were recruited into a Pilot phase prospective randomized study and operated in a single institution by bariatric teams with >300 SAGB experience. In 2 patient groups, intraoperative and immediate postoperative outcomes of the SAGB QuickClose (SAGB QC) classic titanium port and Velocity™ port were compared. Recorded parameters were: preoperative BMI and sex; duration of port implantation (min); length of incision (mm); complications (signs of infection/skin reaction, port-torsion, protrusion, etc); port-site pain scoring (day 1, end of week 1 and 6 postoperatively). Results and Conclusions: 1) Velocity™ port implantation time was significantly shorter than that in classic titanium port (mean 2.5 min vs 6 min, P<0.01). 2) Port-site skin incision was longer in the Velocity™ group (45 mm) compared to the classic titanium port group (35 mm). 3) Reduction in patient subjective pain complaints in favor of Velocity™ port recipients was noted in the immediate postoperative period but no difference at 6 weeks after the operation. 4) Port-site infection occurred in 1 patient from the classic titanium port group and in none in the Velocity™ group.

Laparoscopic sleeve gastrectomy without over-sewing of the staple line is effective and safe

Introduction Laparoscopic sleeve gastrectomy (LSG) is a bariatric procedure with very good long-term weight-reducing and metabolic effects. Aim Here we report 6 years’ experience with LSG performed in morbidly obese patients by one surgical team focusing on the impact of the degree of sleeve restriction and safety of the procedure without over-sewing the staple line. Material and methods From 2006 to 2012, 207 morbid obese patients with average age of 43.4 years and average body mass index 44.9 kg/m2 underwent LSG without over-sewing the staple line. The complete 5- and 3-year follow-up is recorded in 59 and 117 patients with prospective data collection at 3, 6, 9, 12, 18, 24, 36, 42 and 60 months after LSG. Group 1 patients operated in 2006–2008 had smaller sleeve restriction. Group 2 patients operated in 2009–2012 had major sleeve restriction. All procedures were performed without over-sewing of the staple line. Results The average %EBMIL (excess body mass index loss) in group 1 patients with minor sleeve restriction reached 54.1% and average %EWL (excess weight loss) was 50.8% while in group 2 with major sleeve restriction the average %EBMIL reached 69.7% and average %EWL was 66.8%. Final weight reduction was significantly higher in group 2 patients compared to group 1 patients with smaller sleeve restriction. Out of 49 patients with preoperatively diagnosed T2DM (type 2 diabetes mellitus) was completely resolved in 70.8%. Pre-operatively diagnosed hypertension normalized in 64.2%, improved in 23.2%, and remained unchanged in 12.6% of patients. Conclusions Carefully performed LSG without over-sewing the staple line is feasible and safe. A better weight-reducing effect was present in patients with major sleeve restriction.

Bariatric Surgery at the 1st Surgical Department in Prague: History and Some Technical Aspects

Background: Obesity has been increasing in the Czech Republic over the last 20 years. In 1983 we were one of the first surgical departments in the country which performed bariatric surgery on a regular basis. Methods: From 1983 to 1986 we performed vertical banded gastroplasty (VBG). Because of a high rate of various complications arising both from the stomach and the wound, we switched in 1986 to ‘less aggressive’ nonadjustable gastric banding (GB). In 1993 we performed the first laparoscopic nonadjustable banding, and in 1994 we started laparoscopic placement of adjustable gastric bands. Results: In the group of 52 patients who underwent VBG and were followed-up, acceptable weight loss results (−40.5 kg) were achieved in the 24 months following surgery. The postoperative complications were high; 17.3% gastric staple-line disruption and 15.3% wound complications (incisional hernias, discharge, etc.). Since 1986, we have performed nonadjustable GB in 150 patients and achieved weight loss of -38.4 kg in the 24 months following surgery. There was no change in the wound complication rate, but the complications arising from the stomach and the band decreased to 6.3%. Since June 1993, we have performed 268 procedures laparoscopically, either with nonadjustable bands or, since 1994, with the adjustable bands. The wound complication rate decreased to 0.9%, and one complication (6.6%) was related with the adjustable band. Conclusions: Because of the high rate of post-operative complications in our experience with VBG, we started GB in 1986. Since then the number of complications arising from the stomach has decreased substantially. With the laparoscopic technique, there was a further decrease in wound healing problems. With the adjustable GB, a significant decrease in the stomach-related complications occurred. Shorter hospital stays were possible with the laparoscopic technique. Long-term weight loss results have not been significantly different among the above mentioned procedures.