Wojciech K. Karcz

The first teleautomatic low-voltage prosthesis with multiple therapeutic applications: a new version of the German artificial sphincter system.

To date, there are no artificial sphincter prostheses for urinary or fecal incontinence that may be implemented elsewhere instead, for example, in the upper gastrointestinal tract. Conventional systems are conceptually similar but are constructed specifically for distinct applications and are manual in operation. The German Artificial Sphincter System (GASS) II is the evolution of a highly integrative, modular, telemetric sphincter prosthesis with more than one application. Redesigning and integrating multilayer actuators into the pump allows us to reduce the input voltage to -10 to +20 V (V(PP) = 30 V). This provides for a flow rate of 2.23 mL/min and a counterpressure stability of 260 mbar. Furthermore, multiple applications have become feasible due to our standardized connection system, therapy-specific compression units, and application-specific software. These innovations allow us to integrate not only severe fecal and urinary incontinence, erectile dysfunction, and therapy-resistant reflux disease, but also morbid adiposity into the gamut of therapeutic GASS applications.

Banded sleeve gastrectomy using the GaBP ring--surgical technique.

Laparoscopic sleeve gastrectomy (LSG) has been described as the first step of a two-step laparoscopic Roux-en-Y gastric bypass (LRYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) in extremely obese patients. It has also been used as an independent bariatric procedure. Recently a banded sleeve gastrectomy using human dermis was published. Gastric sleeve dilatation is one of the unfavorable postoperative courses that may limit weight loss. Our technique of a banded sleeve gastrectomy using the GaBP Ring AutolockTM System to calibrate the sleeve and prevent distal sleeve dilatation is described in this article.

Laparoscopic Pylorus-Preserving Pancreatic Head Resection and Hybrid Open Reconstruction via Pancreatogastrostomy

IntroductionLaparoscopic pancreatic surgery is ambitious and should only be performed in institutions with expert knowledge in pancreatic surgery.MethodsWhereas pancreatic tail resection is routinely and safely performed in several institutions, the laparoscopic resection of the pancreatic head is only performed by a handful of surgeons.ResultsIn this article, we present our hybrid approach with complete laparoscopic pylorus-preserving pancreatic head resection and successive reconstruction via a small retrieval incision, which might combine the advantages of the laparoscopic resection with the safety of an open and routine pancreatic anastomosis.

Pitfalls and Technical Aspects during the Research of Intestinal Anastomotic Healing in Rats

Background: Fundamental experimental research into intestinal anastomotic healing in rodent models will gain increasing interest in the future. Methods: The aim of this study was to describe our 5-year experience with a standardized experimental setup of small and large bowel anastomoses in a rodent model and present a basic set of assessment tools investigating anastomotic healing. Anastomotic technique, perioperative complications such as anastomotic insufficiency (AI) and obstructive ileus were in the focus. Results: During different studies with varying study patterns, 167 rat small bowel anastomoses and 120 colonic anastomoses were performed. Overall mortality was 3.6% in small bowel and 2.5% in colonic anastomoses, AI occurred in 2.9 and 4%, respectively. A postoperative obstructive ileus was seen in 3/167 small bowel anastomoses and none in the colonic group. Conclusion: When performing experimental intestinal anastomoses in a standardized operative setting and critically considering special perioperative issues, the incidence of relevant complications can be maintained at an adequately low level.

Laparoscopic extirpation of a fork from the duodenum

BackgroundA 23-year-old woman who 2 weeks before visiting our institution swallowed a plastic fork while attempting to induce vomiting during a party presented with progressive abdominal pain. Various techniques for removing foreign bodies from the intestinal tract have been described. We present the laparoscopic retrieval of a 15-cm fork from the duodenal bulb.MethodsThe patient presented with leukocytosis and epigastric tenderness. An upper endoscopy revealed a plastic fork, tines up, perforating the duodenal bulb. The handle was irremovably lodged in the opposite part of the duodenum. Perforating objects and objects larger than 7 cm ought to be removed surgically to prevent esophageal perforation. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, two 10-mm and two 5-mm, were used. We saw a slight swelling of the duodenum with few fibrin stripes and roughly 250 ml of white exudate. The fork tines were visible; there were no injuries to the liver. The tines were held with a clamp while the perforated intestinal wall was carefully dissected with a monopolar hug and later with an ACE harmonic scalpel due to bleeding. The fork was extracted in the proximal direction through the perforation injury. There was no severe necrosis and debridement was not necessary. The bowel was irrigated and continuously sutured with 3-0 PDS. Finally, the fork was retrieved through the 10-mm trocar incision.ResultsOperating time was 60 min and blood loss was roughly 100 ml. The patient’s postoperative course was uneventful. One year after intervention, the patient is doing well.ConclusionA fork may be swallowed, but usually does not spontaneously pass through the gastrointestinal tract. Early removal should be advised to avoid perforation and to minimize morbidity. Laparoscopic removal is a safe and feasible method of managing foreign bodies that are not removable endoscopically.

Integrated concept of treatment for reduction of morbidity after resection of panniculus morbidus associated with lymphoedema

Abstract A subgroup of grossly obese patients may develop a large hanging abdominal apron, panniculus morbidus, which can contain an element of lymphoedema. This hinders normal activities and prevents adequate hygiene. We reviewed published reports and found that the complications that result from resection of a panniculus had been well described, but the presence of lymphoedema and the possible benefit of appropriate physiotherapy was not addressed. Our first aim was to assess our overall morbidity. Secondly we assessed whether perioperative complex decongestive physical therapy had the potential to reduce the incidence of commonly encountered complications. We retrospectively reviewed the casenotes of all massively obese patients who had panniculectomies between 1998 and 2008. We identified two groups of patients, in the first of which were 38 patients who were given perioperative complex decongestive physical therapy (CDP). In the second group were 18 patients who had no additional treatment perioperatively. We then compared the differences between the groups in the incidence of complications, reoperation rate, duration of hospital stay, and wound complications. All the patients not given perioperative treatment developed a postoperative complication. Only 6 patients in the treated group had minor wound problems. The rates and severity of complications associated with this type of operation can be improved if the patient has access to additional care in a specialised rehabilitation centre during the perioperative period.

Ileal transposition in rats influenced glucosemetabolism and HSP70 levels

Abstract Objective: Ileal transposition procedure (IT), in combination with sleeve gastrectomy, is widely used to induce diabetes remission and to control related metabolic abnormalities. A transposition of a long segment of distal ileum in obese Zucker rats improved glucose tolerance 6 months after IT. The premise of our study was to to examine the long - term effects of ileum transposition on the liver glycolytic enzymes content in a euglycemic group of operated Zucker rats. Methods: Twenty male Zucker rats underwent either the transposition of 50% distal ileum or a sham surgery. Six months after surgery, liver tissue concentrations of glycogen synthase kinase alpha (GSK-3α), glucose 6-phosphatase (G6PC), glycogen phosphorylase (PYGM) and phosphofructokinase (PFK) and HSP70 were assessed by immunoenzymatic methods. Results: HSP70 values were significantly higher in the IT group compared to SHAM. G6PC liver concentrations in the IT group were almost 1.45-fold lower than in the SHAM operated rats. Statistical analyses (F-test) showed HSP70 levels were significantly related to caveolin-1and SHAM group. Conclusions: Lowered glycolytic enzyme concentrations assessed in the liver suggest positive effects on glucose metabolism in long-term observations.

Reconstruction of leaking gastric pouch after redo Rouxen-Y gastric bypass – revisionary surgery strategy

With the rapid development of the knowledge and techniques in bariatric surgery, as well as extensive expansion of indications for metabolic operations, surgeons have started to realize that the procedures they choose are not always suited to the needs and behavior of patients. Second and very frequently third revisional procedures are thus necessary in order to achieve desired outcomes and fulfill patients’ expectations. Restoration of restriction is commonly the first procedure, but not all may benefit from it. We hence want to illustrate the decision-making process by presenting a patient with the background of initial Rouxen-Y gastric bypass (RYGB) and redo-RYGB, who then underwent a further revision by a 2-stage approach due to weight regain. The first stage involved shortening of the common channel and the second one reconstruction of his gastric pouch with duodenal switch (DS). Consequently we wish to focus here on a discussion about operative techniques and strategies to improve outcomes in such patients.

Fusion of duodeno-ileal omega switch and stomach pouch reconstruction as revisionary surgery for failed laparoscopic adjustable gastric banding and sleeved lesser curvature resection

Revisionary bariatric surgery procedures are becoming more frequent. Facing the challenge of complicated digestive tract changes after redo surgery, it is crucial to choose an appropriate method. Duodeno-ileal omega switch (DIOS), with growing clinical value as an easy malabsorptive procedure, has emerged as a treatment option. We would like to present a case of a 52-year-old obese male patient with a history of laparoscopic adjustable gastric banding and removal of a lesser curvature as a revision procedure to restore the restriction. In order to improve the patients health outcome, a two-stage re-revision procedure was performed, including DIOS to reduce the weight of the patient and a gastric pouch reconstruction in order to achieve a better satiety effect. This case study illustrates the intrinsic potential of malabsorption surgery and makes us believe that it may be used as the primary operation in two-staged procedures for revisionary surgical treatment.

Metabolic surgery in zucker rats influenced miRNA, caveolin-1 expression and lipid metabolism

Abstract Aims: A transposition of the long segment of distal ileum in obese Zucker rats improved glucose tolerance 6 months after IT. It was undertaken to compare the gene expression of miRNA-103, -107 and caveolin-1 in the liver of euglycemic groups of IT relative to SHAM operated rats. Main methods: Obese, male Zucker rats underwent either transposition of 50% distal ileum or sham surgery. For determining the gene expression, the Real-Time PCR for caveolin-1 and miRNA-103, -107 was performed. Plasma concentrations of LDL, HDL, TG and total cholesterol were measured with enzymatic colorimetric assays after optimization procedure. Key findings: The Cav-1 expression in liver tissue after ileal transposition was 1.22 times higher compared to the SHAM group (SHAM median 63.58, min 41.3, max 82.4; IT median 77.35, min 60.8, max 95.41, p < 0.001). miRNA-107 expression was significantly downregulated by 0.6-fold in the IT group compared to the SHAM group (SHAM median 507.51, min 236.42, max 721.29; IT median 355.2, min 278.15, max 478.15, p < 0.015. The level of TG was significantly higher after IT surgery (SHAM median 115, min 96, max 143; IT median 153, min 115, max 162, p = 0.001). The total cholesterol plasma levels decreased after IT (SHAM median 178, min 161, max 183; IT median 128, min 103, max 114, p < 0.000001). The LDL plasma level in IT was two-fold lower than in the SHAM (SHAM median 117, min 68, max 151; IT median 58, min 45, max 61, p < 0.000001). Significance: The transposition of 50% of the distal ileum lead to an increase in caveolin-1 and reduction in miR-107 expression compared to those of SHAM group. Endogenous miR-107 is more involved in regulation of the functions of insulin-target liver tissue than miRNA-103. Reduced LDL and cholesterol plasma levels suggest positive effects on lipid metabolism in long-term observations. The present study is the first to show a lack of IT effect regarding triglycerides six months after surgery.