Zeev Dreznik

Impact of Gastric Banding on Plasma Ghrelin, Growth Hormone, Cortisol, DHEA and DHEA-S Levels

Background: Several endocrine abnormalities are reported in obesity. Some are considered as causative factors, whereas others are considered to be secondary effects of obesity. In the current study, we explored the changes in cortisol, growth hormone (GH), DHEA, DHEA-S and GH releasing hormone (ghrelin) plasma levels in morbidly obese subjects who lost abundant weight following laparoscopic adjustable gastric banding (LAGB). Methods: 12 morbidly obese adult patients (15 females), age 21-56 years with BMI 46.0±4.4 kg/cm2, were studied. Blood samples were collected before, 6 and 14 months after LAGB. The levels of DHEA, DHEA-S, cortisol, GH, and ghrelin were determined by commercial kits. Statistical analysis was based on one-way repeated measures ANOVA, followed by Student-Newman-Keuls post-hoc test. Results: Mean BMI reduced significantly along the study course (P=.000). Cortisol plasma levels significantly decreased 6 months after surgery (from 541.4±242.4 nM to 382.4±142.1 nM, P=.004), but did not change further after 14 months (460.2±244.9 nM), despite further reduction in BMI (P=.050). GH constantly increased throughout the study from 0.076±0.149ng/ml, to 0.410±0.509 ng/ml at 6 months (NS), to 1.224±1.738 ng/ml at 14 months after surgery (P=.001). DHEA, DHEA-S and ghrelin plasma levels remained stable throughout the study. Conclusions: GH levels showed a persistent increase during the 14 months following LAGB in association with the weight loss, while a transient decrease in cortisol levels occurred at the 6-months time-point. In contrast, ghrelin, DHEA and DHEA-S were not altered after surgery. The association between GH and cortisol secretion and surgical- and nonsurgical-induced weight reduction merits further investigation.

Harmonic scalpel hemorrhoidectomy: preliminary results of a new alternative method

Abstract. Surgical treatment is considered to be the best therapeutic modality for severe hemorrhoidal disease. Different surgical methods of hemorrhoidectomy aim to decrease pain, bleeding, stenosis and discharge. The aim of this study was to evaluate the efficacy of harmonic scalpel hemorrhoidectomy. During a period of seven months, 54 consecutive patients with third- and fourth-degree hemorrhods were prospectively randomized for harmonic scalpel hemorrhoidectomy (HS) or Milligan-Morgan procedure (MM). These patients were examined at one, two, and six weeks after the operation. All patients had a lower gastrointestinal investigation prior to operation to exclude other colorectal pathologies. All patients had the same kind of preoperative preparation and analgesia during the postoperative course. Pain was assessed using a visual analog scale from 0 to 10. Patient satisfaction was defined as decrease or absence of symptoms and return to normal daily activities. HS groups included 29 patients, while the MM group had 25 patients. There as no difference between the groups in terms of age, gender, hemorrhoidal degree and indication for operation. The types of intra-operative anesthesia administered to the two groups were similar. Duration of surgery was significantly higher in the MM group (p<0.0001). Postoperative hospitalization was longer in the MM group (p<0.0001), and the pain degree was higher in MM group (p<0.0001). No significant difference was noted in the overall amount of analgesics used in the two groups at week 1, although it was significantly higher in the MM group 2 and 3 weeks after the operation. Early complication occurred more frequently in the MM group but overall the difference was not statistically significant. In conclusion, harmonic scalpel hemorrhoidectomy is virtually a bloodless operation with minimal tissue damage. It is associated with significant less postoperative pain and a fast return to normal activity.

General Anesthesia for Surgery Influences Melatonin and Cortisol Levels

The purpose of this study was to investigate the effect of general anesthesia and surgery on melatonin production, and to assess the relationship between melatonin secretion and cortisol levels. Twenty (9 males and 11 females) consecutive otherwise healthy patients aged 27 to 52 years were included in this study. The patients underwent laparoscopic cholecystectomy or laparoscopic hernioplasty. All patients had general anesthesia with the same anesthetic drugs. Serum cortisol levels were measured at several time periods. Urine collections for melatonin were performed from 18:00 to 7:00 the day prior to surgery, on the operation day, and on the first postoperative day. Baseline melatonin metabolites were measured the night prior to surgery, and the level was found to be 1979 ± 1.76 ng. The value decreased to 1802 ± 1.82 ng (NS) on the night of surgery, and it became a significantly higher, reaching 2981 ± 1.55 ng the night after surgery (p = .003). The baseline daytime cortisol level was significantly lower than the baseline night cortisol level (6.87 ± 1.51 μg/dl, 14.89 ± 1.66 micrograms/dl, respectively, p < 0.0001). Surgery induced a significant increase in both day and night cortisol levels. Daytime cortisol levels increased from 6.89 ± 1.51μg/dl to 16.90 ± 1.27μg/dl (p < 0.0001), whereas right levels increased from 14.89 ± 1.66 μg/dl to 29.20 ± 1.24 μg/dl (p <0.0001). The morning after surgery, cortisol levels decreased to 10.16 ± 1.40 μg/dl, lower than the value obtained on the day of surgery (p < 0.0001). As was true of melatonin, cortisol levels did not reach the pre operative level (p < 0.005). The finding of the current study is that melatonin and cortisol levels show an inverse correlation after surgery.

The Relationship between BMI, Plasma Leptin, Insulin and Proinsulin Before and After Laparoscopic Adjustable Gastric Banding

Background: Morbid obesity is associated with over-secretion of leptin and insulin, and predisposes to development of carbohydrate intolerance. In the current study, we explored the impact of BMI after laparoscopic adjustable gastric banding (LAGB) on leptin, insulin and proinsulin levels. Methods: 23 obese patients (8 males, 15 females) were included in the study. Their mean age was 36±6 yrs (range 21–56 yrs). Blood samples were collected for measurement of plasma leptin, insulin and proinsulin before and 6 and 14 months after LAGB. Results: Mean BMI before surgery was 46.04 ± 4.44 kg/m2, with significant and equal reduction of 18% in each of the follow-up periods, with total BMI reduction of 33% (P <.0001). The levels of circulating leptin, insulin and proinsulin before intervention were 119.3 ± 53.1 ng/ml, 159 ± 13 pmol/l, and 36.36 ± 23.06 pmol/l respectively. Despite an equal BMI reduction in the 2 follow-up periods, the most significant decrease in hormone levels was observed in the immediate postoperative period (54, 53, and 45%, respectively), when compared to the second follow-up period (15, 30, 10%, respectively). The highest total decline in hormone level of 70% was obtained with insulin, compared to 52% in leptin, and 50% in proinsulin. Despite the significant decrease in proinsulin and insulin levels, their ratio increased from 0.22, to 0.28 and 0.36 after LAGB. Unlike insulin and proinsulin, leptin levels strongly and persistently correlated with BMI during the study. Conclusion: Following LAGB, weight loss was associated with decreased levels of circulating leptin, insulin and proinsulin, most prominent in the first follow-up period. Unlike insulin and proinsulin, leptin showed the most significant and persistent correlation with BMI, suggesting that morbid obesity acts through different feedback hormonal mechanisms which are probably not regulated only by absolute weight loss. Longer follow-up and larger numbers of patients are needed to clarify long-term hormonal profile, as well as the beneficial lasting effects of such interventions.

Rectal flap advancement – a simple and effective approach for the treatment of rectourethral fistula

Objectiveu2003 Rectourethral fistula is a rare complication of prostatic surgery and other pelvic procedures. We report our experience of surgical repair of using a rectal advancement flap.

Silastic Ring Vertical Gastroplasty— Long-term Results and Complications

Background: Silicone ring vertical gastroplasty (SRVG) in some reports is associated with significant morbidity and a tendency to regain weight in the late postoperative period. The present study aims to evaluate our long-term results, along with early and late postoperative complications. Methods: The early and late postoperative complications of 300 patients undergoing SRVG and followed for an average of 3.2 years, were reviewed retrospectively .The pre- and post-operative weight and body mass index (BMI) were recorded in a subgroup of 131 patients with an average follow-up of 5.2 years. Results: Early postoperative complications occurred in 99 patients (33.1%), with mortality of one patient (0.3%).Vomiting was the most common late complication, occurring in 49.3%. Re-operation was performed in 19.7% of the patients, mostly for the repair of postoperative ventral hernia. Long-term results following SRVG showed a decrease in weight from 131 ± 25 kg to 94 ± 23.2 kg, and BMI decreased from 46.1 ± 8.1 kg /m2 to 32.9 ± 7.4 kg/m2. Excess body weight loss was 58.5 ± 39.8% . Conclusions: Most patients (76%) reported their satisfaction following SRVG. Long-term results revealed a significant and sustained weight loss, mild complications and low mortality rate.

Emergency surgery for complicated acute diverticulitis.

Aimu2002 Antecedent attacks of diverticulitis are thought to increase the risk of complicated diverticulitis, and unless elective surgery is performed, a high proportion of patients with recurrent symptoms will require emergency operations for complicated diverticulitis with its associated morbidity. In this multicentre study, we aim to assess impact of previous attacks of diverticulitis on patients requiring an emergency surgical intervention.

Impact of Gastric Banding on Plasma Adiponectin Levels

Background: Several endocrine abnormalities are reported in obesity. In an earlier study, we found that the changes in BMI following laparoscopic adjustable gastric banding (LAGB) were associated with changes in hormone profiles such as insulin and proinsulin. In the current study, we explored the changes in plasma adiponectin levels in morbidly obese subjects who lost abundant weight following LAGB. Methods: 23 adult morbidly obese patients (15 females), aged 21-56 years, were studied. Blood samples were collected before, and 6 and 14 months after LAGB. The plasma adiponectin levels were determined by commercial kit (B-Bridge International, Inc). Statistical analysis was based on one-way repeated measures ANOVA, followed by Student-NewmanKeuls post-hoc test. Regression model was used to look for predictors of adiponectin change after LAGB. Results: Mean BMI before surgery was 46.04±4.44 kg/m2, and decreased significantly by 18% 6 months after surgery to 37.67±4.47 kg/m2. BMI further decreased by 32% 14 months after surgery to a mean of 31.30±4.65 kg/m2 (P =.000). The mean adiponectin level before surgery was 3997±1766 μg/ml, and increased significantly by 16% to 4763±1776 μg/ml 6 months after surgery, and to 6336±3292 μg/ml (37%) 14 months after surgery. Although BMI persistently decreased, while adiponectin persistently increased, BMI did not correlate with adiponectin. Conclusion: In morbidly obese patients who underwent LAGB, adiponectin levels persistently increased, probably due to the reduction of visceral fat mass. Adiponectin plasma increase was correlated with proinsulin levels prior to the surgery. The interaction between adiponectin, proinsulin and BMI change in morbid obesity merits further investigation.

Rectal Prolapse: A Possibly Underrecognized Complication of Anorexia Nervosa Amenable to Surgical Correction

Objective: Rectal prolapse is a complication of AN that may be more common than previously recorded experience would suggest. Method: In this report we document, for the first time, the association of anoxia nervosa (AN) and rectal prolapse in a series of three patients seen in the past three years. An extensive review of the literature using Medline over the period from 1966 to Jan 2000 failed to reveal any previous example of this association. Results and Conclusion: The finding could have significant health care implications if confirmed. It would suggest that patients with either the psychiatric or surgical problem may not be receiving the appropriate complementary referrals: psychiatrist to surgeon and vice versa. The importance of recognition of this association in anorectic patients is the availability of effective surgical therapy.

Resting Anal Pressure Following Hemorrhoidectomy and Lateral Sphincterotomy

PURPOSEThe role of high anal pressure in the pathophysiology of hemorrhoids and anal fissures is debated. We compared resting anal pressures following left lateral sphincterotomy and hemorrhoidectomy in a prospective manometric study with emphasis on the recovery of the internal anal sphincter activity.METHODSIncluded in the study were 38 patients with third-degree or fourth-degree symptomatic hemorrhoids who underwent hemorrhoidectomy, 50 patients with anal fissure who underwent sphincterotomy, and 12 healthy patients who served as controls. All patients with anal fissure or hemorrhoids underwent periodic manometric evaluation: 1 month before surgery and 1, 3, 6, and 12 months after surgery. The control group had three manometric evaluations 6 months apart.RESULTSBaseline pressure measurement in the fissure group was significantly higher than in the hemorrhoid group, which was significantly higher than in the control group (138 ± 28.4 mmHg vs. 108.4 ± 23 mmHg vs. 73 ± 5.9 mmHg, P < 0.0001). Twelve months after surgery, anal resting pressure remained significantly lower than the baseline measurements in both the fissure (110 ± 18.2 vs. 138 ± 28.4, P < 0.0001) and hemorrhoid groups (103.6 ± 21.5 vs. 108 ± 23, P < 0.0001), but both remained higher than the control group (103.6 ± 21.5 mmHg vs. 73 ± 5.9 mmHg, P < 0.0001).CONCLUSIONSResting pressure is elevated in hemorrhoid and anal fissure patients. After surgery the anal resting pressure is reduced but is still higher than in the control group. Further studies are required to investigate the protective effect of postsurgical reduction of anal resting pressure against recurrence.