Tadeusz Wróblewski

Prospective randomized clinical trial of laparoscopic sleeve gastrectomy versus open Roux-en-Y gastric bypass for the management of patients with morbid obesity.

Introduction Roux-en-Y gastric bypass (RYGB) is considered the gold standard bariatric procedure with documented safety and effectiveness. Laparoscopic sleeve gastrectomy (LSG) is a newer procedure being done with increasing frequency. Randomized comparisons of LSG and other bariatric procedures are limited. We present the results of the first prospective randomized trial comparing LSG and RYGB in the Polish population. Aim To assess the efficacy and safety of LSG versus RYGB in the treatment of morbid obesity and obesity-related comorbidities. Material and methods Seventy-two morbidly obese patients were randomized to RYGB (36 patients) or LSG (36 patients). Both groups were comparable regarding age, gender, body mass index (BMI) and comorbidities. The follow-up period was at least 12 months. Baseline and 6 and 12 month outcomes were analyzed including assessment of percent excess weight lost (%EWL), reduction in BMI, morbidity (minor, major, early and late complications), mortality, reoperations, comorbidities and nutritional deficiencies. Results There was no 30-day mortality and no significant difference in major complication rate (0% after RYGB and 8.3% after LSG, p > 0.05) or minor complication rate (16.6% after RYGB and 10.1% after LSG, p > 0.05). There were no early reoperations after RYGB and 2 after LSG (5.5%) (p > 0.05). Weight loss was significant after RYGB and LSG but there was no difference between both groups at 6 and 12 months of follow-up. At 12 months %EWL in RYGB and LSG groups reached 64.2% and 67.6% respectively (p > 0.05). There was no significant difference in the overall prevalence of comorbidities and nutritional deficiencies. Conclusions Both LSG and RYGB produce significant weight loss at 6 and 12 months after surgery. The procedures are equally effective with regard to %EWL, reduction in BMI and amelioration of comorbidities at 6 and 12 months of follow-up. Laparoscopic sleeve gastrectomy and RYGB are comparably safe techniques with no significant differences in minor and major complication rates at 6 and 12 months.

1000 liver transplantations at the Department of General, Transplant and Liver Surgery, Medical University of Warsaw--analysis of indications and results.

THE AIM OF THE STUDY was to analyze indications and results of the first one thousand liver transplantations at Chair and Clinic of General, Transplantation and Liver Surgery, Medical University of Warsaw. MATERIAL AND METHODS Data from 1000 transplantations (944 patients) performed at Chair and Clinic of General, Transplantation and Liver Surgery between 1994 and 2011 were analyzed retrospectively. These included 943 first transplantations and 55 retransplantations and 2 re-retransplantations. Frequency of particular indications for first transplantation and retransplantations was established. Perioperative mortality was defined as death within 30 days after the transplantation. Kaplan-Meier survival analysis was used to estimate 5-year patient and graft survival. RESULTS The most common indications for first transplantation included: liver failure caused by hepatitis C infection (27.8%) and hepatitis B infection (18%) and alcoholic liver disease (17.7%). Early (< 6 months) and late (> 6 months) retransplantations were dominated by hepatic artery thrombosis (54.3%) and recurrence of the underlying disease (45%). Perioperative mortality rate was 8.9% for first transplantations and 34.5% for retransplantations. Five-year patient and graft survival rate was 74.3% and 71%, respectively, after first transplantations and 54.7% and 52.9%, respectively, after retransplantations. CONCLUSIONS Development of liver transplantation program provided more than 1000 transplantations and excellent long-term results. Liver failure caused by hepatitis C and B infections remains the most common cause of liver transplantation and structure of other indications is consistent with European data.

Ghrelin, leptin, and glycemic control after sleeve gastrectomy versus Roux-en-Y gastric bypass—results of a randomized clinical trial

BACKGROUND Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cause weight loss and metabolic improvement, but results of published studies are contradictory. OBJECTIVES The aim of this study was to compare the effects of SG and RYGB on ghrelin, leptin, and glucose homeostasis in a randomized controlled trial. SETTING University hospital, Poland. METHODS Seventy-two morbidly obese patients were randomly selected to undergo either SG (n = 36) or RYGB (n = 36). Fasting ghrelin, leptin, glucose, insulin, C-peptide, glucagon, glycated hemoglobin, and homeostasis model assessment of insulin resistance were assessed preoperatively and at 1, 6, and 12 months postoperatively. No differences were found in anthropometric and biochemical parameters between the study groups at baseline. RESULTS Sixty-nine (95.8%) patients completed the study. Percentage of excess weight loss at 12 months was 67.6±19.3% after SG and 64.2±18.5% after RYGB (P>.05). Fasting ghrelin levels decreased 1 month after SG (from 76.8 pmol/L to 35.3 pmol/L; P<.05) and remained reduced until 12 months (41.6 pmol/L; P<.05) but increased 12 months after RYGB from 74.6 pmol/L to 130.2 pmol/L (P<.05). Leptin, glucose, insulin, and C-peptide concentrations and glycated hemoglobin and homeostasis model assessment of insulin resistance values decreased significantly in both groups during 12 months. CONCLUSIONS RYGB and SG induce comparable weight loss and improvement in metabolism of glucose. Ghrelin levels decrease after SG and increase after RYGB, but this difference does not affect similar outcomes of these procedures during 1-year follow-up. The contribution of ghrelin to weight loss or metabolic benefits after bariatric surgery is not straightforward, but rather influenced by multiple factors.

Stereoscopic liver surface reconstruction

The paper presents a practical approach to measuring liver motion, both respiratory and laparoscopic, with a tool guided in the operating room. The presented method is based on standard operating room equipment, i.e. rigid laparoscopic cameras and a single incision laparoscopic surgery trocar. The triangulation algorithm is used and stereo correspondence points are marked manually by two independent experts. To calibrate the cameras two perpendicular chessboards, a pinhole camera model and a Tsai algorithm are used. The data set consists of twelve real liver surgery video sequences: ten open surgery and two laparoscopic, gathered from different patients. The setup equipment and methodology are presented. The proposed evaluation method based on both calibration points of the chessboard reconstruction and measurements made by the Polaris Vicra tracking system are used as a reference system. In the analysis stage we focused on two specific goals, measuring respiration and laparoscopic tool guided liver motions. We have presented separate examples for left and right liver lobes. It is possible to reconstruct liver motion using the SILS trocar. Our approach was made without additional position or movement sensors. Diffusion of cameras and laser for distance measurement seems to be less practical for in vivo laparoscopic data, but we do not exclude exploring such sensors in further research.

Liver Function in Patients With Nonalcoholic Fatty Liver Disease Randomized to Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy: A Secondary Analysis of a Randomized Clinical Trial

Objectives: The aim of the study was to compare the influence of sleeve gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB) on liver function in bariatric patients with non-alcoholic fatty liver disease (NAFLD) in a randomized clinical trial (NCT01806506). Background: Rapid weight loss and malabsorption after bariatric surgery in patients with NAFLD or steatohepatitis (NASH) may impair liver function. Methods: Sixty-six morbidly obese patients randomized to SG or RYGB were included in a secondary outcome analysis. Intraoperative liver biopsies were categorized with NAFLD Activity Score (NAS) and liver function tests were done before surgery and after 1, 6 and 12 months. Results: NASH was present in 54.5% RYGB and 51.5% SG patients (P > 0.05). At 12 months excess weight loss was 68.7 ± 19.7% after SG and 62.8 ± 18.5% after RYGB (P > 0.05). At 1 month international normalized ratio (INR) increased after RYGB (0.98 ± 0.05 vs 1.14 ± 0.11; P < 0.05) and SG (0.99 ± 0.06 vs 1.04 ± 0.06; P < 0.05), RYGB induced significantly greater increase in INR in the whole group and NASH patients than SG. After RYGB albumin decreased at 1 month (41.2 ± 2.7 vs 39.0 ± 3.2 g/L; P < 0.05). At 12 months, INR and albumin returned to baseline. At 12 months in NASH group, SG induced significant improvement in aspartate aminotransferase (32.4 ± 17.4 vs 21.5 ± 6.9U/L), alanine aminotransferase (39.9 ± 28.6U/L vs 23.8 ± 14.1U/L), gamma-glutamyl transpeptidase (34.3 ± 16.6 vs 24.5 ± 16.8U/L), and lactate dehydrogenase (510.8 ± 33 vs 292.4 ± 29). Variables predictive of INR change after 1 month included operation type, NAS ≥ 5, bilirubin, body mass index, hemoglobin A1C, and dyslipidemia. Conclusions: Patients with NASH undergoing RYGB are more susceptible to early transient deterioration of liver function than after SG.

Myeloproliferative neoplasms and recurrent thrombotic events in patients undergoing liver transplantation for Budd-Chiari syndrome: a single-center experience.

BACKGROUND Budd-Chiari syndrome is a heterogeneous disease. The role of liver transplantation as a treatment option has been discussed since 1976. Many cases are related to underlying myeloproliferative neoplasms associated with prothrombotic propensity. The aim of this study was to evaluate the long-term clinical outcome after liver transplantation for Budd-Chiari syndrome at our center, with special emphasis on recurrent thrombosis and underlying myeloproliferative disorders. MATERIAL/METHODS A medical records search revealed 25 patients transplanted at our center for Budd-Chiari syndrome between 2000 and 2009. Indications for transplantation were complications of end-stage liver disease or acute liver failure. RESULTS Ten patients were men (40.0%). Median age of recipients at transplantation was 29.0 (17-51) years. Eighteen patients (72%) had evidence of myeloproliferation, 1 had paroxysmal nocturnal hemoglobinuria, and 6 had idiopathic disease. In 55.5% of cases eventually diagnosed with myeloproliferative neoplasms, Budd-Chiari syndrome was their initial presentation. All patients were maintained on long-term post-transplant anticoagulation protocol. The median follow-up time was 58.8 months. Four patients (16%) died during follow-up. Acute graft rejection occurred in 16% of cases. During the observation period, 5 patients had recurrent thrombotic events. The 5-year patient and graft survival rate was 84%. No case of transformation to acute leukemia was seen. CONCLUSIONS Our data show satisfactory long-term survival of patients and grafts in the study group. Occult course of myeloproliferative neoplasms is frequent in this population and exceeds 50%. We observed recurrent thrombosis in 20% of recipients.

Effect of mesh type, surgeon and selected patients’ characteristics on the treatment of inguinal hernia with the Lichtenstein technique. Randomized trial

Introduction Though not entirely free of complications, the Lichtenstein technique is still considered the “gold standard” for inguinal hernia repair due to the low recurrence rate. Aim In our study we determined the effect of mesh type, surgeon and selected patients’ characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence. Material and methods Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7th day as well as in the 3rd and 6th month after the operation. Statistical analysis was performed with multi-factor regression models. Results In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patients general condition and body mass. Conclusions Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients’ characteristics have a significant impact on the treatment outcome.

Continuous registration based on computed tomography for breathing motion compensation

Introduction Image guidance for intervention is applied for complex and difficult anatomical regions. Nowadays, it is typically used in neurosurgery, otolaryngology, orthopedics and dentistry. The application of the image-guided system for soft tissues is challenging due to various deformations caused by respiratory motion, tissue elasticity and peristalsis. Aim The main task for the presented approach is continuous registration of preoperative computed tomography (CT) and patient position in the operating room (OR) without touching the patient and compensation of breathing motion. This approach is being developed as a step to image-guided percutaneous liver RF tumor ablation. Material and methods Up to ten integrated radiological markers are placed on the patients skin before CT scans. Then the anatomical model based on CT images is calculated. Point-to-point registration based on the Horn algorithm during a few breathing cycles is performed using a videometric tracking system. The transformation which corresponds to the minimum fiducial registration error (FRE) is found during the registration and it is treated as the initial transformation for calculating local deformation field of breathing motion compensation based on the spline approach. Results For manual registration of the abdominal phantom, the mean values of target registration error (TRE), fiducial localization error (FLE) and FRE are all below 4 mm for the rigid transformation and are below 1 mm for the affine transformation. For the patients data they are all below 9 mm and 6 mm, respectively. For the automatic method, different marker configurations have been evaluated while dividing the respiratory cycle into inhale and exhale. Average median values for FRE, TRE rigid estimation and TRE based on spline deformation were 15.56 mm, 0.82 mm and 7.21 mm respectively. Conclusions In this application two registration methods of abdominal preoperative CT anatomical model and physical patient position in OR were presented and compared. The presented approach is being developed as a step to image-guided percutaneous liver radiofrequency ablation tumor ablation. Implementation of the automated registration method to clinical practice is easier because of shortening of preparation time in OR, no necessity of touching the patient, and no dependency on the physicians experience.

Randomized clinical trial comparing inguinal hernia repair with Lichtenstein technique using non-absorbable or partially absorbable mesh. Preliminary report

Introduction The Lichtenstein technique is currently considered the “gold standard” of open, anterior inguinal hernia repair. It is not free, however, of adverse effects, which may be caused by the implemented synthetic material. Aim Determination the influence of the mesh employed on treatment results including immediate complications, return to everyday activities, chronic pain occurrence and hernia recurrence. Material and methods Tension-free hernia repair using the Lichtenstein technique was performed in all the 59 patients randomized to trial groups. Group P with heavyweight polypropylene mesh contained 34 patients; group V with lightweight, partially absorbable mesh (polypropylene/polyglactin 910) consisted of 25 people. Controlled, scheduled follow-up appointments took place after the 7th day and the 3rd and 6th month. Patients were clinically assessed and pain intensity was determined on an analogue-visual scale. Results No statistically significant influence of the type of mesh on the risk of early complications, severe pain intensity, the length of hospital stay, time of recovery, or patients’ satisfaction with treatment was observed. After 6 months also no statistically significant differences were observed between groups with regard to recurrence rate (P 3.4% vs. V 4.0%), chronic pain (P 5.9% vs. V 4.0%) and ailments such as “foreign body presence” (V vs. P, OR = 0.30, 95% CI 0.077-1.219, p = 0.093) incidence, although their probability was 70% lower for V mesh. Conclusions The preliminary results confirm the effectiveness of the Lichtenstein technique for hernia repair with both types of meshes. It appears that use of a partially absorbable mesh is connected with lower risk of postoperative complications, but the final results require multicentre trials in a larger series of patients.

In-vitro evaluation of stereoscopic liver surface reconstruction

Introduction Tracking abdominal motion of organs is an important factor in image-guided navigation systems. The paper presents the evaluation methodology of a practical approach to measure liver motion, both respiratory and laparoscopic, with a tool guided in the operating room. Aim Evaluation of the methodology of a practical approach to measure liver motion, both respiratory and laparoscopic, with a tool guided in the operating room. Material and methods The presented evaluation method is based on standard operating room equipment, i.e. laparoscopic cameras. We decided to use two rigid cameras to gain stereo in order to reconstruct characteristic points by triangulation. Our research aim was to survey the impact of three parameters on reconstruction accuracy: the number of calibration points, the imprecision of camera assembly, and the difference in resolution of images. Results Three calibration chessboard configurations were tested. The reconstructed landmark positions and residual mean square errors were presented in three phantom poses: the reference position, translated position and rotated position. Conclusions The presented approach is a development of the previous work. Our research proved the importance of a rigid stereo camera system and the use of high definition image resolution for both stages, namely calibration and reconstruction.