Paweł Lech

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.

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.

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.

Does previous abdominal surgery affect the course and outcomes of laparoscopic bariatric surgery

BACKGROUND Global experiences in general surgery suggest that previous abdominal surgery may negatively influence different aspects of perioperative care. As the incidence of bariatric procedures has recently increased, it is essential to assess such correlations in bariatric surgery. OBJECTIVES To assess whether previous abdominal surgery influences the course and outcomes of laparoscopic bariatric surgery. SETTING Seven referral bariatric centers in Poland. METHODS We conducted a retrospective analysis of 2413 patients; 1706 patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) matched the inclusion criteria. Patients with no history of abdominal surgery were included as group 1, while those who had undergone at least 1 abdominal surgery were included as group 2. RESULTS Group 2 had a significantly prolonged median operation time for RYGB (P = .012), and the longest operation time was observed in patients who had previously undergone surgeries in both the upper and lower abdomen (P = .002). Such a correlation was not found in SG cases (P = .396). Groups 1 and 2 had similar rates of intraoperative adverse events and postoperative complications (P = .562 and P = .466, respectively). Group 2 had a longer median duration of hospitalization than group 1 (P = .034), while the readmission rate was similar between groups (P = .079). There was no significant difference between groups regarding the influence of the long-term effects of bariatric treatment on weight loss (percentage of follow-up was 55%). CONCLUSIONS Previous abdominal surgery prolongs the operative time of RYGB and the duration of postoperative hospitalization, but does not affect the long-term outcomes of bariatric treatment.

Clinical evaluation of C-reactive protein and procalcitonin for the early detection of postoperative complications after laparoscopic sleeve gastrectomy

Introduction Among the most common early complications after bariatric surgery are anastomosis leak and bleeding. In order to react quickly and perform accurate treatment before the clinical signs appear, early predictors should be found. In the study C-reactive protein (CRP) and procalcitonin (PCT) levels were investigated. Characterized by a relatively short half-life, they can predict surgical complications. Aim To develop and implement certain standards for early detection of complications. Material and methods The study involved 319 adults who underwent laparoscopic sleeve gastrectomy (LSG) as a surgical intervention for morbid obesity at the Department of General Surgery of Ceynowa Hospital in Wejherowo. Every patient had CRP and PCT levels measured before the surgery and on the 1st and 2nd postoperative day (POD). Results Early postoperative complications occurred in 19 (5.96%) patients. Septic and non-septic complications occurred in 3 and 16 patients respectively. Among the patients with septic postoperative complications CRP level increased significantly on the 2nd POD compared to the remainder (p = 0.0221). Among the patients with non-septic postoperative complications CRP level increased significantly on the 1st and 2nd POD compared to the remainder. Among the patients with septic and non-septic postoperative complications PCT level increased significantly on the 2nd POD compared to the remainder. Conclusions The CRP and PCT level are supposed to be relevant diagnostic markers to predict non-septic and septic complications after LSG.

Hybrid (laparoscopy + stent) treatment of celiac trunk compression syndrome (Dunbar syndrome, median arcuate ligament syndrome (MALS))

Introduction Celiac trunk (CT) compression syndrome caused by the median arcuate ligament (MAL) is a rarely diagnosed disease because of its nonspecific symptoms, which cause a delay in the correct diagnosis. Intestinal ischemia occurs, which causes symptoms of abdominal angina. One method of treatment for this disease is surgical release of the CT – the intersection of the MAL. Laparoscopy is the first step of the hybrid technique combined with percutaneous angioplasty and stenting of the CT. Aim To demonstrate the usefulness and advantages of the laparoscopic approach in the treatment of Dunbar syndrome. Material and methods Between 2013 and 2016 in the General and Minimally Invasive Surgery Department of the Medical Sciences Faculty of the University of Warmia and Mazury in Olsztyn, 6 laparoscopic procedures were performed because of median arcuate ligament syndrome. During the laparoscopy the MAL was cut with a harmonic scalpel. One month after laparoscopy 5 patients had Doppler percutaneous angioplasty of the CT with stent implantation in the Vascular Surgery Department in Pomeranian Medical University in Szczecin. Results In one case, there was a conversion of laparoscopic surgery to open due to unmanageable intraoperative bleeding. In one case, postoperative ultrasound examination of the abdominal cavity demonstrated the presence of a large hematoma in the retroperitoneal space. All patients reported relief of symptoms in the first days after the operation. Conclusions The hybrid method, combining laparoscopy and angioplasty, seems to be a long-term solution, which increases the comfort of the patient, brings the opportunity for normal functioning and minimizes the risk of restenosis.

The usefulness of biliopancreatic diversion/Scopinaro operation in treatment of patients with Prader-Willi syndrome.

Prader-Willi syndrome (PWS) is the most common form of obesity with a genetic basis. The short expected survival time due to numerous accompanying diseases and their complications is the reason for research on the maximally efficient method of treatment of obesity in this syndrome. Undertaken attempts of conservative treatment, for example with somatostatin, are ineffective. It seems that the only effective treatment of obesity in this syndrome may be surgical. In this article we present 2 cases of patients with PWS who underwent surgery consisting of biliopancreatic diversion (BPD)/Scopinaro procedure. The BPD/Scopinaro operation in selected cases of disciplined patients with a co-operative family, which we find of key importance, can be considered as one option of treatment of this syndrome in patients with prior neglect of conservative treatment.