Th. Manger

Aktuelle Daten der Qualitätssicherungsstudie für operative Therapie der Adipositas in Deutschland

BACKGROUND Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg. METHODS The voluntary data registration occurs in an internet online data bank. All primary bariatric procedures as well as re- and redo-procedures are documented. Follow-up data were collected once a year. Participation in the quality assurance study is obligatory for certificated centres. RESULTS Since 2005 13,879 bariatric procedures have been performed at 83 hospitals. The number of primary procedures has increased from 596 in 2005 to 11,835 in 2010. Revisional surgery has been performed in 1,438 patients since 2005. Sleeve gastrectomy (SG) is the major procedure with 1,564 operations in 2010. The mean BMI was 48.8 kg/m². The incidence of comorbidities was 84.8%. CONCLUSION Bariatric surgery has become more accepted in Germany. Beside the Roux-en-Y gastric bypass, sleeve gastrectomy is the most frequently performed operation. BMI and incidence of comorbidities are still high in comparison with literature values. Due to the lack of evidence, more randomised studies are necessary to standardise operative techniques and evaluate patient selection criteria. Quality assurance studies support a detailed analysis of these parameters.

Alterations of the p16/MTS1-Tumor Suppressor Gene in Gastric Cancer

Deletions, mutations and the functional inactivation of tumor suppressor gene p16 are involved in the genesis of different neoplasias. Little is known about the role of p16 gene alterations in the genesis of gastric carcinomas. This study aimed to detect genetic alterations of the p16 gene in gastric carcinomas. We analyzed p16 gene mutations and the frequency of loss of heterozygosity (LOH) at the p16 locus in 43 gastric carcinomas. PCR-SSCP analysis of exons 1 and 2 revealed only one gene mutation in a carcinoma of the diffuse type. Besides carcinomas of the diffuse, intestinal and the mixed type, we also investigated a small-cell primary gastric carcinoma, which was the only one to show a deletion in the p16 gene. LOH analysis was performed using two polymorphic markers located near the p16 gene (D9S171, D9S162) and a sequence-tagged-site marker (c5.1). Allelic loss was noted in two carcinomas of the diffuse type and in one carcinoma of the intestinal type. Allelic instabilities were found in one tumor of the intestinal type and diffuse type each. Although only five of 43 (11.6%) gastric carcinomas had p16 alterations, tumors of the diffuse type tend to show a higher number of genetic alterations near the p16 locus.

Gastrointestinale Stromatumoren (GIST) – Probleme in Diagnostik und Therapie

Summary. Gastrointestinal stromal tumors (GIST), which form a rare group of neoplasias of the gastrointestinal tract, have not yet been fully investigated. Although good progress has been made in their diagnosis, classification of these lesions with regard to their histogenesis and biological behavior remains problematic. Between 1994 and 1998, 18 GIST patients underwere operation in the Department of Surgery. Twelve of these patients (67 %) had stromal tumors in the stomach, and six (33 %) had intestinal stromal tumors. The primary tumor could be removed in all patients with R0 resection. Six patients developed hematogenous liver metastasis, with the size of their primary tumor exceeding 10 cm. Extrahepatic distant metastases were not found in any case. Lymphadenectomy showed that lymph node metastases did not occur. Histological evaluation was made according to the guidelines of Lewin, Weinstein and Riddell. Currently established therapy is limited to complete surgical resection of the primary tumor and its metastases. Adjuvant or neoadjuvant chemotherapy approaches have failed.Zusammenfassung. Die gastrointestinalen Stromatumoren (GIST) sind eine seltene, auch heute noch nicht vollständig aufgeklärte Gruppe von Neoplasien des Magen-Darm-Trakts. Trotz vieler Fortschritte der diagnostischen Möglichkeiten ist eine Zuordnung der GIST hinsichtlich ihrer Histogenese und Dignität nicht eindeutig. Im Zeitraum von 1994 bis 1998 wurden in der Klinik für Chirurgie 18 Patienten mit einem GIST operiert. Dabei handelte es sich um 12 (67 %) gastrale und 6 (33 %) intestinale Stromatumoren. Der Primärtumor konnte bei allen Patienten durch eine R0-Resektion entfernt werden. Bei 6 Patienten kam es zu einer hämatogenen Lebermetastasierung, die Größe des Primärtumors betrug bei diesen Patienten mehr als 10 cm. Eine extrahepatische Fernmetastasierung ließ sich in allen untersuchten Fällen nicht nachweisen. Eine Lymphknotenmetastasierung konnte in den regionären Lymphknoten nicht festgestellt werden. Eine systematische Lymphadenektomie ist nicht indiziert. Die histologische Beurteilung der Dignität erfolgte auf der Grundlage der von Lewin, Weinstein und Riddell vorgeschlagenen Richtlinien. Das derzeit gesicherte therapeutische Vorgehen besteht in der kurativen Resektion des Primärtumors sowie der Metastasen mit histologisch tumorfreien Resektionsrändern. Das Tumorrezidiv ist ebenso zu behandeln. Adjuvante oder neoadjuvante chemotherapeutische Ansätze zeigen bisher keine Erfolge.

Risk of thrombosis and thromboembolic prophylaxis in obesity surgery: data analysis from the German Bariatric Surgery Registry

BackgroundEvidence-based data on optimal approach for prophylaxis of deep venous thrombosis (VTE) and pulmonary embolism (PE) in bariatric operations is discussed. Using antithrombotic prophylaxis, weight adjusted the risk of VTE and its complications have to be balanced with the increased bleeding risk.MethodsSince 2005, the current situation for bariatric surgery has been examined by quality assurance study in Germany. As a prospective multicenter observational study, data on the type, regimen, and time course of VTE prophylaxis were documented. The incidences of clinically diagnosed VTE or PE were derived during the in-hospital course and follow up.ResultsOverall, 31,668 primary bariatric procedures were performed between January 2005 and December 2013. Most performed operations were 3999 gastric banding (GB); 13,722 Roux-en-Y-gastric bypass (RYGBP); and 11,840 sleeve gastrectomies (SG). Gender (p = 0.945), surgical procedure (p = 0.666), or administration of thromboembolic prophylaxis (p = 0.272) had no statistical impact on the DVT incidence. By contrast, BMI (p = 0.116) and the duration of thromboembolic prophylaxis (p = 0.127) did impact the frequency of onset of DVT.ConclusionAge, BMI, male gender, and a previous history of VTE are the most important risk factors. The drug of choice for VTE is heparin. LMWH should be given preference over unfractionated heparins due to their improved pharmacological properties, i.e., better bioavailability and longer half-life as well as ease of use. Despite the low incidence of VTE and PE, there is a lack of evidence. Therefore, prospective randomized studies are necessary to determine the optimal VTE prophylaxis for bariatric surgical patients.

Revisions- und „Redo“-Eingriffe in der Adipositas- und metabolischen Chirurgie

BACKGROUND Increasing numbers of interventions for obesity and metabolic surgery have led to an increase of primary bariatric operations as well as redo operations and revisional surgery after various primary bariatric procedures. Evidence-based guidelines for indications and choice of procedure for revisional surgery do not currently exist. AIM The spectrum of various revisional and redo operations following standard operative procedures for obesity and metabolic surgery is presented based on current data from the German bariatric surgery registry (GBSR, German nationwide survey on quality assurance in bariatric surgery) and a literature search. MATERIAL AND METHODS Since 1 January 2005, the current situation of bariatric surgery has been examined using the GBSR. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Since 2005 a total of 24,070 primary bariatric procedures, 2070 revisional procedures and 1124 redo operations were analyzed. The study evaluated 1021 revisional and 491 redo operations after gastric banding (GB), 443 redo operations after sleeve gastrectomy (SG) and 306 revisional procedures and 10 redo operations after a Roux-en-Y gastric bypass (RYGBP). RESULTS Reoperations of GB to SG were performed in 240 cases. The complication rate for GB removal and SG showed a significantly higher leakage rate for one step operations than for two step procedures of 3.3% vs. 0.0%. Conversion of GB to RYGBP was performed in 402 operations without any significant differences between one and two step approaches (1.9% vs. 2.2%). The specific complication rate in the 443 interventions in patients for conversion from SG to RYGBP was 10.8% which is higher than for primary SG (4.9%) and RYGBP (5.3%). CONCLUSION Compared with the primary surgical procedures redo operations and revisional procedures have significantly higher complication rates. The data evaluated show that strong and differentiated indications are necessary for revisional and redo operations particularly in cases of therapy or metabolic failure.

Nutritive Defizite nach bariatrischer Chirurgie – systematische Literaturanalyse und Empfehlungen für Diagnostik und Substitution

The increasing prevalence of morbid obesity in Germany is associated with an increasing number of metabolic surgical interventions. Short-term surgical and long-term metabolic complications such as nutrient deficiencies can be considered the main risks of metabolic surgery and its restrictive and malabsorbant surgical procedures. The aim of this compact short overview based on a selective literature search and our own clinical experience is to characterise the long-term metabolic complications, which are specific for the various bariatric procedures, and to refine the published guidelines for supplementation. Restrictive bariatric procedures can be associated with well-known surgical problems such as pouch dilatation or band migration, e.g., after gastric banding. After sleeve gastrectomy, emerging reflux disease can become a substantial problem. The most frequent deficiencies after restrictive procedures are related to B-vitamins whereas iron, folate, vitamin B1 and B12 and vitamin D deficiencies are associated with the malabsorptive procedure such as biliopancreatic diversion, duodenal switch and Roux-en-Y gastric bypass. Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long medical follow-up investigations. The currently available guidelines of German Society of Treatment of Obesity (CAADIP) of DGAV for supplementation should be known and followed, in particular, by the physicians who i) are exceptionally involved in medical care of obese people and ii) do it in full awareness of the obligatory postoperative clinical observation.

[Revisional surgery and reoperations in obesity and metabolic surgery : Data analysis of the German bariatric surgery registry 2005-2012].

BACKGROUND Increasing numbers of interventions for obesity and metabolic surgery have led to an increase of primary bariatric operations as well as redo operations and revisional surgery after various primary bariatric procedures. Evidence-based guidelines for indications and choice of procedure for revisional surgery do not currently exist. AIM The spectrum of various revisional and redo operations following standard operative procedures for obesity and metabolic surgery is presented based on current data from the German bariatric surgery registry (GBSR, German nationwide survey on quality assurance in bariatric surgery) and a literature search. MATERIAL AND METHODS Since 1 January 2005, the current situation of bariatric surgery has been examined using the GBSR. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Since 2005 a total of 24,070 primary bariatric procedures, 2070 revisional procedures and 1124 redo operations were analyzed. The study evaluated 1021 revisional and 491 redo operations after gastric banding (GB), 443 redo operations after sleeve gastrectomy (SG) and 306 revisional procedures and 10 redo operations after a Roux-en-Y gastric bypass (RYGBP). RESULTS Reoperations of GB to SG were performed in 240 cases. The complication rate for GB removal and SG showed a significantly higher leakage rate for one step operations than for two step procedures of 3.3% vs. 0.0%. Conversion of GB to RYGBP was performed in 402 operations without any significant differences between one and two step approaches (1.9% vs. 2.2%). The specific complication rate in the 443 interventions in patients for conversion from SG to RYGBP was 10.8% which is higher than for primary SG (4.9%) and RYGBP (5.3%). CONCLUSION Compared with the primary surgical procedures redo operations and revisional procedures have significantly higher complication rates. The data evaluated show that strong and differentiated indications are necessary for revisional and redo operations particularly in cases of therapy or metabolic failure.

Thoracoscopic enucleation of benign tumors of the esophagus under simultaneous flexible esophagoscopy

AbstractBackground: Benign tumors of the esophagus are very rare, accounting for only 0.1–2% of all esophageal tumors. Conventional treatment consists of thoracotomy adapted to the location of the tumor, followed by enucleation of the lesion. This approach, however, involves major surgery. Minimally invasive surgery represents a viable therapeutic alternative, in particular for benign tumors. Methods: In four patients with a benign tumor of the esophagus, we carried out thoracoscopic enucleation under simultaneous esophagoscopy. Results: Using this combination of endoscopic procedures, the tumors were removed reliably and safely. Two of the lesions were intramural leiomyomas, and two were intramural myxoid cysts. Conclusion: This combination of endoscopic procedures represents a minimally invasive approach with correspondingly minor surgical trauma. Using simultaneous esophagoscopy and transillumination (diaphanoscopy) of the esophageal wall, the safety and accuracy of the dissection is increased, and the risk of mucosal perforation minimized.

Das venöse angiomatöse Hamartom der Mesenterialwurzel Therapie von Chylascites und Chylothorax – eine Kasuistik

Summary. Hamartomas are rare benign tumors appearing very often without any symptoms. In case of diagnostic detection the operative exploration is indicated for a correct histological diagnosis and resection. In this report we describe a very rare case of mesenterial hamartoma. During the late postoperative course a refilling chylothorax and chylous ascites occurred. With total parenteral nutrition, excluding short- and long-chain fatty acids, chylous leakage was successfully treated. The chylous exudation was stopped totally; only intraabdominally did minimal ascites persist. The therapy was continued by a oral Ceres diet nutrition. The conservative therapy involving total parenteral nutrition permitted us to avoid the peritoneovenous LeVeen shunt and the associated complications.Zusammenfassung. Als seltene gutartige Tumore bleiben Hamartome häufig symptomlos. Ihr Nachweis rechtfertigt eine operative Exploration zur Befundsicherung und Resektion. Am vorliegenden Fall berichten wir über ein seltenes mesenteriales Hamartom. Im späten Verlauf nach partieller Resektion traten komplizierend ein rezidivierender Chylothorax und Chylascites auf. Konsequente totale parenterale Nutrition (TPN) unter Exclusion von kurz- und langkettigen Fettsäuren erbrachte das völlige Sistieren der chylösen Absonderungen im Thorax bei Verbleiben eines Restascites im Abdomen. Durch Fortführung einer Ceres®-Diät wurde ambulant der Therapieerfolg gesichert. Die komplikationsbeladene Anlage eines peritoneovenösen Shunts nach LeVeen konnte dadurch vermieden werden.

Revisions- und „Redo“-Eingriffe in der Adipositas- und metabolischen Chirurgie@@@Revisional surgery and reoperations in obesity and metabolic surgery: Datenanalyse des German Bariatric Surgery Registry 2005–2012@@@Data analysis of the German bariatric surgery registry 2005–2012

BACKGROUND Increasing numbers of interventions for obesity and metabolic surgery have led to an increase of primary bariatric operations as well as redo operations and revisional surgery after various primary bariatric procedures. Evidence-based guidelines for indications and choice of procedure for revisional surgery do not currently exist. AIM The spectrum of various revisional and redo operations following standard operative procedures for obesity and metabolic surgery is presented based on current data from the German bariatric surgery registry (GBSR, German nationwide survey on quality assurance in bariatric surgery) and a literature search. MATERIAL AND METHODS Since 1 January 2005, the current situation of bariatric surgery has been examined using the GBSR. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Since 2005 a total of 24,070 primary bariatric procedures, 2070 revisional procedures and 1124 redo operations were analyzed. The study evaluated 1021 revisional and 491 redo operations after gastric banding (GB), 443 redo operations after sleeve gastrectomy (SG) and 306 revisional procedures and 10 redo operations after a Roux-en-Y gastric bypass (RYGBP). RESULTS Reoperations of GB to SG were performed in 240 cases. The complication rate for GB removal and SG showed a significantly higher leakage rate for one step operations than for two step procedures of 3.3% vs. 0.0%. Conversion of GB to RYGBP was performed in 402 operations without any significant differences between one and two step approaches (1.9% vs. 2.2%). The specific complication rate in the 443 interventions in patients for conversion from SG to RYGBP was 10.8% which is higher than for primary SG (4.9%) and RYGBP (5.3%). CONCLUSION Compared with the primary surgical procedures redo operations and revisional procedures have significantly higher complication rates. The data evaluated show that strong and differentiated indications are necessary for revisional and redo operations particularly in cases of therapy or metabolic failure.