Reinhard Mittermair

Retrospective evaluation of carcinoid tumors of the appendix in children

Carcinoids of the appendix are rare in children and are usually diagnosed incidentally on histologic investigation following appendectomy for appendicitis. To investigate the significance of the diagnosis of appendiceal carcinoid in children, we conducted a retrospective study of the treatment and follow-up of 36 children with histologically confirmed carcinoid tumors of the appendix. Between 1970 and 2000 a total of 36 patients (25 girls, 11 boys) were diagnosed with appendiceal carcinoid. The median age of the patients at diagnosis was 12.3 years (range 6–16 years). The indication for appendectomy was acute lower right quadrant pain in 27 cases and chronic right lower quadrant pain in 9 patients. In 27 specimens the tumor was localized at the apex, in 7 at the midportion, and in 2 at the base of the appendix. The median tumor diameter was 6 mm (range 3–17 mm). Concomitant severe appendicitis was diagnosed in 14 patients 2 with a perforated appendicitis. In only one tumor were mucin-producing cells detectable. After a median follow-up of 10 years (range 2 months to 30 years) all patients were tumor-free. None of the patients had a synchronous or metachronous noncarcinoid malignant tumor. Appendiceal carcinoids are usually asymptomatic, and the indication for surgical Intervention is acute or chronic abdominal pains in the right lower quadrant. For most patients the prognosis is excellent after appendectomy. As in adults, appendectomy is the appropriate treatment.RésuméLes tumeurs carcinoïdes de l’appendice sont rares chez l’enfant et sont diagnostiqués habituellement de façon fortuite sur la pièce d’appendicectomie réalisée pour syndrome appendiculaire. Afin d’évaluer la signification du diagnostic de tumeur carcinoïde chez l’enfant, nous avons réalisé une étude rétrospective du traitement et du suivi chez 36 enfants porteurs d’une tumeur carcinoïde de l’appendice. Entre 1970 et 2000, on a fait le diagnostic de tumeur carcinoïde de l’appendice chez 36 patients, 25 filles et 11 garçons, dont l’âge médian au moment du diagnostic a été de 12.3 ans (extrêmes: 6–16 ans). L’indication de l’appendicectomie a été une douleur aiguë de la fosse iliaque droite dans 27 cas et une douleur chronique de la fosse iliaque droite chez 9 patients. En ce qui concerne la localisation de la tumeur, sur 27 pièces, la tumeur a été localisée à la pointe dans 18 cas, dans la portion moyenne pour sept cas, et chez deux, à la base. La médiane du diamètre a été de 6 mm (extrêmes: 3–17 mm). Chez 14 patients on a diagnostiqué une appendicite sévère concomitante, deux fois avec perforation. On a détecté des cellules riches en mucine dans une seule tumeur. Après un suivi d’une médiane de 10 ans (extrêmes: 2 mois-30 ans,) tous les patients étaient sans tumeur. Aucun des patients n’a eu de tumeur maligne non carcinoïde synchrone ou métachrone. Les tumeurs carcinoïdes de l’appendice sont habituellement asymptomatiques et l’indication d’intervention chirurgicale est la douleur aiguë ou chronique de la fosse iliaque droite. Pour la plupart des patients, le pronostic est excellent après appendicectomie. Comme chez l’adulte, l’appendicectomie est le traitement approprié.ResumenEn el niño los tumores carcinoides de apéndice son muy raros y se diagnostican al efectuar el estudio histopatolôgico del apéndice extirpada por apendicitis. Para averiguar la transcendencia clïnica del carcinoide apendicular infantil, se realiza un estudio retrospectivo del tratamiento y evolución clïnica de 36 niños con diagnôstico de carcinoide apendicular confirmado histopatológicamente. Entre 1970 y 2000, 36: 25 niñas y 11 niños, fueron diagnosticados de carcinoma apendicular. La edad media de los pacientes fue 12.3 años (rango 6–16 años). La indicación de apendicectomia vino dada, en 27 casos por dolor agudo en el cuadrante inferior derecho y en 9 por molestias crónicas. En 27 especïmenes el tumor estaba situado en el apex, en 7 en la porción media y en 2 en la base apendicular. El diámetro medio del tumor fue de 6 mm (rango 3–17 mm). En 14 casos el carcinoide coincidïa con una apendicitis aguda y en 2 con apendicitis perforada. En sólo un tumor se detectaron células productoras de mucina. Tras un seguimiento medio de 10 anos (rañgo 2 meses-30 años) todos los pacientes estaban sanos. Ninguno desarrolló tumores malignos no carcinoides ni sincrónicos ni metacrónicos. Los carcinoides apendiculares son, por lo general, asintomáticos y la indicación quirúrgica se establece por dolor agudo o crónico en el cuadrante inferior derecho. Para la mayoría de los pacientes el pronóstico, tras apendicectomía, es excelente. Al igual que en los adultos, la apendicectomía constituye el tratamiento de elección.

Uncommon Intragastric Migration of the Swedish Adjustable Gastric Band

Background:The aim of this study was to assess the incidence of intragastric migration of the Swedish adjustable gastric band (SAGB) and to evaluate the safety and effectiveness of gastroscopic band removal. Methods: Between January 1996 and December 2001, 454 patients (381 women, 73 men) underwent a laparoscopic SAGB operation. All data (age, gender, pre- and postoperative weight, time of weight gain, band filling status, endoscopic diagnosis of migration, total weight reduction) were prospectively collected in a computerized data bank. Results: Out of the 454 SAGB operations,14 (3.1%) intragastric band migrations were observed. The average preoperative weight was 122.2 kg and the average postoperative minimum weight was 80.4 kg. All 14 patients had unexplained weight gain on an average of 20 months after the operation. The average band filling status was 8.2 ml. In 12 patients, the band was removed endoscopically, avoiding laparotomy.The remaining 2 patients are under endoscopic surveillance.The mean operating time was 120 minutes. No peri- or postoperative complication was observed. Conclusion: Intragastric band migration is a rare complication and should be considered if a patient starts to regain weight. Migration does not require immediate therapy and therefore this complication could be safely treated endoscopically.

Band Leakage after Laparoscopic Adjustable Gastric Banding

Background: Laparoscopic adjustable gastric banding is effective in inducing weight loss, as well as being minimally invasive, totally reversible, and adjustable to the patients needs. Nevertheless, leakage of the adjustable balloon is a known complication. The aim of this study was to assess the incidence and reasons for balloon leakage of the Swedish adjustable gastric band (SAGB). Patients and Methods: Between January 1996 and December 2002, 566 patients (475 women, 91 men) underwent a laparoscopic SAGB implantation. Two groups of patients were analyzed: patients with early postoperative leakage (Group E) and patients with late postoperative leakage (Group L). All data (age, gender, pre- and postoperative weight, time of weight gain, band filling status) were prospectively collected in a computerized data bank. For the detection of gastric band leakage, radiography and the technetium-99m colloid scintigraphy was used. Results: 25 band leakages were observed in 22 patients (4.4%). All these patients had a silent presentation of band leakage, with weight regain and an ability to eat without major restriction. Band leakages in group E were detected during the band filling period after a median follow-up of 8 months and after 30.3 months (P <0.0001) in group L. In group E, all 13 leakages possibly resulted from inappropriate handling of the device during surgery. In 2 cases in group L, a tear of the balloon had occurred where it is fixed to the band. The other 10 bands showed breaks at the edges of the inner side of the balloon. All leakages could be detected by 99mTc colloid scintigraphy, whereas only 58% of the leakages could be detected by radiography. Conclusion: Band leakage is a rare complication and should be considered if a patient starts to regain weight. Operative failure as well as material defects may account for this complication. The balloon leakage can effectively be detected by 99mTc colloid-scintigraphy.

Effects of Adjustable Gastric Banding on Altered Gut Neuropeptide Levels in Morbidly Obese Patients

Background: Patients with gastroesophageal reflux disease (GERD) have alterations of gut neuropeptides, such as neurotensin (N) and motilin (M), which are resolved following antireflux surgery. Obesity is associated with GERD. Since the adjustable gastric band prevents gastroesophageal reflux in morbidly obese patients, this study was performed to investigate plasma levels of N and M before and after adjustable gastric banding (AGB). Methods: 47 morbidly obese patients were operated laparoscopically using the Swedish AGB. Preand postoperatively basal plasma levels of N and M were investigated. Symptoms such as heartburn, regurgitation and dysphagia were documented, and esophageal manometry as well as 24-hour pH-monitoring were performed pre- and postoperatively. 11 non-obese, asymptomatic, age-matched volunteers served as controls. Results: After a median postoperative follow-up period of 268 days, a significant weight reduction was observed. Preoperatively, 14 patients suffered from reflux symptoms. An insufficient lower esophageal sphincter (LES) was found in 8 patients, and 2 patients had impaired esophageal body motility. Pathologic pH-testing was found in 6 patients. Postoperatively, reflux symptoms were present in 4 patients; LES findings and pH-testing were normalized in all patients. However, there was significant impairment of esophageal peristalsis. Preoperatively, levels of N were significantly decreased and levels of M increased compared with control subjects. Postoperatively, there was a significant increase of N and levels of M were normalized. Alterations in gut neuropeptides did not correlate with reflux symptoms, impaired gastroesophageal motility, age, gender or BMI. Conclusion: Morbid obesity alters gut neuropeparetides, which are resolved by AGB. This may be caused by reduction of hypercaloric nutrition post-operatively rather than by improvement of gastroesophageal reflux.

Adjustable Gastric Banding: Assessment of Safety and Efficacy of Bolus-Filling during Follow-Up

Background: Individual band-filling on demand of the morbidly obese patient is a major advantage of adjustable gastric banding. An increasing number of patients results in an enormous amount of outpatient follow-up visits, which inspired us to compare a stepwise band-filling strategy with a single bolus injection 4 weeks after the operative procedure. Methods: 40 consecutive patients were prospectively randomized in 2 groups. 20 patients (Group A) had stepwise band-filling during 6 monthly ambulant visits. 20 patients (Group B) had a bolus-filling 4 weeks postoperatively and had the next follow-up after another 5 months. Weight loss, complications and procedural costs during follow-up were compared. Results: Patients of both groups did not differ in age, gender or preoperative BMI.There was no significant difference postoperatively in excess weight lost (EWL) after 9 months. Postoperative complications did not differ significantly.By means of bolus-filling, a 60% and 53% reduction in outpatient clinical work was achieved within the 6 and 9 months, respectively. Conclusion: Postoperative management after gastric banding takes advantage of a single bolus-filling during the first postoperative 6 months due to sufficient weight loss, low complication rate but significant reduction of personal, financial and logistic efforts.

Vertical Mayo Repair of Midline Incisional Hernia: Suggested Guidelines for Selection of Patients

OBJECTIVE To find out whether the vertical Mayo repair should be done for midline incisional hernias. DESIGN Retrospective study. SETTING University hospital, Austria. SUBJECTS 208 patients who presented with a primary midline incisional hernia during the period January 1991 to December 1996. INTERVENTIONS Incisional hernia repair using the vertical Mayo technique. MAIN OUTCOME MEASURES Recurrence rates, risk factors, common practice. RESULTS There were 60 recurrences (29%) and median follow up was 6 years (range 4-8). Four risk factors (cirrhosis, chronic cough, obesity (BMI > 30), and hernia width > 4 cm) were identified, which were independently predictive of hernia recurrence. All 60 patients with a recurrent hernia had at least two of the four risk factors. The remaining 148 patients who did not develop a recurrence had no risk factors, or only one. Recurrence could therefore be predicted with a sensitivity of 80% and a specificity of 96%. CONCLUSION The vertical Mayo repair is a good method for the repair of incisional hernias if not more than one of the four significant risk factors is present. The presence of two or more risk factors is predictive of a high rate of recurrence, and other techniques, such as alloplastic mesh repair, should be considered.

Is it necessary to deflate the adjustable gastric band for subsequent operations

BACKGROUND Laparoscopic adjustable gastric banding (LAGB) is an effective method in the treatment of morbid obesity. However, it is unknown, whether deflating the gastric band before operations under general anesthesia is necessary to avoid complications such as nausea, vomiting, respiratory complications, and weight regain. METHODS Between January 1996 and June 2001, we performed LAGB on 408 patients at the University Hospital of Innsbruck. Of these patients, we identified 68 (16.7%) patients who were to undergo subsequent unrelated general, reconstructive, vascular, or orthopedic procedures. These patients were prospectively randomized into two groups: group 1 (n = 32) preoperative deflation of the adjustable band system and group 2 (n = 36) without preoperative deflation of the adjustable band system. RESULTS There were no anesthetic or perioperative band-related complications in either group 1 or group 2. There were two reoperations necessary due to surgical complications unrelated to the gastric band. CONCLUSIONS Operations after adjustable gastric banding can be safely performed without deflating the adjustable system.

Accuracy of Preoperative Pinhole Subtraction Single Photon Emission Computed Tomography for Patients with Primary and Recurrent Hyperparathyroidism in an Endemic Goiter Area

PurposeBilateral parathyroid exploration is still the standard therapeutic procedure for primary and recurrent hyperparathyroidism (HPTH). Since a unilateral surgical strategy that reduces surgical complications should not increase the risk of missing enlarged parathyroid glands, reliable preoperative imaging is the first requirement for this approach. This study was conducted to assess the accuracy of preoperative 99mTcO4-201T1 pinhole subtraction single photon emission computed tomography (SPECT) compared with sonography.MethodsThe study population consisted of 15 patients with primary (n = 13) or recurrent (n = 2) HPTH who underwent preoperative 99mTcO4-201T1 pinhole subtraction SPECT. Preoperative sonography was also done in 14 of these patients.Results99mTcO4-201T1 pinhole subtraction SPECT was significantly more accurate than sonography. It had an overall accuracy of 80% in detection of enlarged parathyroid glands. The accuracy of localization increased to 92.3% in patients with solitary adenomas, and to 100% in those with solitary adenomas and no previous parathyroid exploration.ConclusionsThe high accuracy of preoperative localization with 99mTcO4-201T1 pinhole subtraction SPECT in patients with primary and recurrent HPTH allows for an imaging-guided unilateral operative strategy in most patients, even those with concomitant nodular goiters. This may reduce the risk of surgical complications and expand the use of minimally invasive techniques in parathyroid surgery.

Transumbilical single-incision laparoscopic sleeve gastrectomy: Short-term results and technical considerations.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has gained popularity and acceptance among bariatric surgeons, mainly due its low morbidity and mortality. Single-incision laparoscopic surgery has emerged as another modality of carrying out the bariatric procedures. While the single-incision transumbilical (SITU) approach represents an advance, especially for cosmetic reasons, its application in morbid obesity at present is limited. We describe our short-term surgical results and technical considerations with SITU-SG. MATERIALS AND METHODS: SITU-SG was performed in 10 patients between June 2010 and June 2011. SG was performed in a standard fashion and was started 6 cm from the pylorus using a 36 French bougie. RESULTS: They were all females with a mean age of 45 years. Preoperative BMI was 40 kg/m2 (range, 35–45). The mean operative time was 98 min. No peri- or postoperative complications or deaths occurred. All patients were very satisfied with the cosmetic outcomes and excess weight loss. CONCLUSION: True SITU laparoscopic SG is safe and feasible and can be performed without changing the existing principles of the procedure.

Single port access sleeve gastrectomy is reasonable

The advantages, we observed, were that the post-operative pain, seemed less compared with the LESS group. Moreover, the postoperative scar was very much better than the single-incision group, and as there were no incisions larger than 5–10 mm, there were less chances of incisional hernia. Above all, the cost of the surgery was almost same as that of conventional laparoscopic surgery. A large scale study is under way to document these observations with respect to pain scores, cosmoses, and cost effectiveness, comparing the two techniques.