Stavros N. Karamanakos

Weight Loss, Appetite Suppression, and Changes in Fasting and Postprandial Ghrelin and Peptide-YY Levels After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy A Prospective, Double Blind Study

Background:Bariatric surgery is currently the most effective treatment in morbidly obese patients, leading to durable weight loss. Objective:In this prospective double blind study, we aim to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGBP) with laparoscopic sleeve gastrectomy (LSG) on body weight, appetite, fasting, and postprandial ghrelin and peptide-YY (PYY) levels. Methods:After randomization, 16 patients were assigned to LRYGBP and 16 patients to LSG. Patients were reevaluated on the 1st, 3rd, 6th, and 12th postoperative month. Blood samples were collected after an overnight fast and in 6 patients in each group after a standard 420 kcal mixed meal. Results:Body weight and body mass index (BMI) decreased markedly (P < 0.0001) and comparably after either procedure. Excess weight loss was greater after LSG at 6 months (55.5% ± 7.6% vs. 50.2% ± 6.5%, P = 0.04) and 12 months (69.7% ± 14.6% vs. 60.5% ± 10.7%, [P = 0.05]). After LRYGBP fasting ghrelin levels did not change significantly compared with baseline (P = 0.19) and did not decrease significantly after the test meal. On the other hand, LSG was followed by a marked reduction in fasting ghrelin levels (P < 0.0001) and a significant suppression after the meal. Fasting PYY levels increased after either surgical procedure (P ≤ 0.001). Appetite decreased in both groups but to a greater extend after LSG. Conclusion:PYY levels increased similarly after either procedure. The markedly reduced ghrelin levels in addition to increased PYY levels after LSG, are associated with greater appetite suppression and excess weight loss compared with LRYGBP.

Laparoscopy in the emergency setting: a retrospective review of 540 patients with acute abdominal pain.

Background Laparoscopy has been widely accepted among surgeons for the diagnosis and management of acute abdominal conditions. In this study, we aim to evaluate and summarize the experience in laparoscopic procedures, both diagnostic and interventional, for emergency nontraumatic abdominal conditions, in a tertiary academic center. Methods From June 2005 to June 2009, a total of 1414 patients were subjected to a variety of emergency procedures at the university hospital of Patras and 540 of these patients were managed laparoscopically (38.2%). Indications for operations in the laparoscopic group were abdominal pain mimicking appendicitis in 229 patients (42.4%), acute cholecystitis in 248 patients (45.9%), gastroduodenal perforated ulcer in 14 patients (2.6%), small bowel obstruction in 24 patients (4.4%), and nonspecific abdominal pain in 25 patients (4.6%). Results Diagnosis was established in 530 patients (98.2%) and definitive laparoscopic treatment was offered to 514 patients (95.2%). The conversion rate was 2.2%. Total mortality was 1.1% and total morbidity was 7.9%. Conclusions Laparoscopic approach to abdominal emergency provides high diagnostic accuracy and therapeutic options. Surgical experience, optimal procedural timing, and appropriate patient selection criteria diminish perioperative mortality and morbidity, and are associated with nominal conversion.

Totally Laparoscopic Management of Gallstone Ileus—Technical Report and Review of the Literature

PURPOSE Gallstone ileus is an uncommon complication of gallstone disease. It occurs in elderly patients in up to 25% of the cases. The management of gallstone ileus remains controversial. Open surgery has been the mainstay of treatment, but laparoscopic surgery has recently been used. In this study we report a case of an 87-year-old female patient with gallstone ileus who has been managed totally laparoscopically, detailing the technique and discussing the advantages of the laparoscopic approach with a review of the literature. METHODS The pneumoperitoneum was established with a Veress needle. A three-port approach (one 5-mm and two 10-mm trocars) and a 30° 10-mm laparoscope were used. The site of obstruction was 5 cm below the ligament of Treitz, and a single gallstone was identified. A 3-cm longitudinal enterotomy was created just above the site where the gallstone was located. An 8-cm-long gallstone was extracted. The enterotomy was closed transversely in a single layer of two sets of continuous sutures. RESULTS The procedure was safely performed with all the advantages of minimally invasive surgery. Previous studies often described laparoscopically assisted procedures for the treatment of gallstone ileus, using a small abdominal incision. In recent years, some reports have been published on the efficacy of the totally laparoscopic approach in the management of gallstone ileus. CONCLUSIONS Totally laparoscopic management of gallstone ileus could be safe and effective with suggested benefits for the elderly patients.

A rare case of intussusception leading to the diagnosis of acquired immune deficiency syndrome: a case report

IntroductionAlthough a common cause of intestinal obstruction in children, intussusception is a rare event in the adult population living in temperate regions. It has long been known that various acquired immune deficiency syndrome related conditions of the bowel such as lymphoma, lymphoid hyperplasia, cytomegalovirus colitis and Kaposis sarcoma can lead to intussusception. The diagnosis is particularly difficult in this population of patients due to the non-specific nature of the symptoms as well as the depressed immune response obscuring inflammation or ischemia. Though the reported acquired immune deficiency syndrome associated cases of intussusception refer to patients with known human immunodeficiency virus infection, in our case we present an intestinal intussusception as the first manifestation of human immunodeficiency virus infection.Case presentationA 58-year-old white heterosexual Greek man with a clean medical record and no history of abdominal operation presented to the emergency department with symptoms and signs of bowel obstruction. Plain abdominal radiographs were highly suspicious for intussusception which was eventually confirmed on a computed tomography scan. Due to the patients clean medical record as well as the radiologic diagnosis of intussusception, we promptly undertook further serologic tests for human immunodeficiency virus and eventually established the diagnosis of acquired immune deficiency syndrome. The patient was operated 3 days later and this confirmed the diagnosis of small-bowel invagination due to a 4 cm polypoid growing intraluminal tumor, the pathologic examination of which revealed a diffuse high-grade B cell lymphoblastic lymphoma.ConclusionHuman immunodeficiency virus infection may have a silent course and gastrointestinal manifestations of the disease leading to intussusception might be the first clinical sign. Patients with intestinal intussusception, and the presence of risk factors for human immunodeficiency virus infection should be eligible for serologic tests for human immunodeficiency virus infection.

Benefits and Drawbacks of SILS Cholecystectomy A Report of 60 SILS Cholecystectomies With Conventional Instrumentation From an Academic Center

Background. Single-incision laparoscopic surgery is a rapidly emerging approach to gallbladder disease. Methods. From February 2009 to September 2010, 60 patients were subjected to single-incision laparoscopic cholecystectomy. In all the patients, a 12-mm incision was made in the umbilicus and a 2-trocar technique was applied. Gallbladder was suspended with 2 sutures and the procedure was accomplished with standard partly reusable laparoscopic instruments. Results. In all, 41 women (68.3%) and 19 men (31.7%) were enrolled in this study. Mean age was 50.7 years (range = 17-72 years), mean body mass index was 26.2 kg/m2 (range = 18.3-37.7 kg/m2) and mean operative time was 52.6 minutes (range = 30-120 minutes). No mortality or morbidity was recorded and hospital stay was less than 24 hours. At follow-up visits, no complications were recorded and cosmesis was excellent. Conclusion. Single-incision laparoscopic cholecystectomy can be safely performed with conventional instrumentation with minimal cost.