Feasibility and Importance of Enteroscopy after Gastric Bypass.

BACKGROUND: Bariatric surgery has increased in popularity, with Roux-en-Y Gastric Bypass (RYGB) being one of the most frequently performed. This leads to many cases in which the stomach is removed from routine gastroscopy access, sometimes being a major source of concern. Performing enteroscopy in these patients is technically difficult. We present our experience with 24 cases in which the aim was to access the detached stomach. METHODS: Retrospective analysis on RYGB enteroscopy procedures aimed to access the detached stomach. Data recorded: demographic parameters, indication, gas insufflation, time to bypass stomach, total procedure and recovery times, and endoscopic and pathological findings. RESULTS: This study included 24 patients who underwent RYGB in the previous 3-36 months. Indications were chronic abdominal pain, refractory anemia, or unexplainable weight loss. Detached stomach was accessed in 79% of patients. Access time ranged from 25 to 55 min. Recovery time for all procedures was 86.66 min on average and shorter with CO2 insufflation (42.5 min). All detached stomachs showed macroscopic gastritis; four of them were Helicobacter pylori positive. Significant findings included three patients with jejunojejunostomy stenosis and one patient with a marginal gastrojejunal ulcer, which was later diagnosed with Signet ring cell carcinoma of the proximal anastomosis. CONCLUSIONS: We present the feasibility and importance of enteroscopy of the detached stomach and believe that this procedure should be performed more frequently. A high index of suspicion is needed for postoperative symptoms in order to exclude significant pathologies and reassure symptomatic patients that there is no abnormality in the bypassed stomach.

Improvement in glycemic control by gastric electrical stimulation (TANTALUS) in overweight subjects with type 2 diabetes.

BACKGROUND: The TANTALUS system (MetaCure Ltd.) is a minimally invasive implantable gastric stimulation modality that does not exhibit malabsorptive or restrictive characteristics. The device applies gastric contractility modulation (GCM) signals to the stomach antrum. The signals are delivered in synchronization to the native electrical activity of the stomach during meals. Retrospective analysis of previous studies indicated that type 2 diabetes mellitus (T2DM) subjects on oral medication with hemoglobin A1c (HbA1c) between 7.5% and 9.5% are the population with most potential benefit from the treatment. The current study includes subjects enrolled prospectively within that range of HbA1c. AIM: To prospectively investigate the potential effect of the TANTALUS system on glycemic control and weight in overweight subjects with T2DM. METHODS: In this European multicenter, open-label study, 13 T2DM obese (6 male, 7 female, BMI 37.2 +/- 1.0 kg/m(2), range 30.4-44.0 kg/m(2)) subjects treated with oral antidiabetic medications but with poor glycemic control (HbA1c > or = 7%, range 7.3-9.5%) were implanted laparoscopically with the TANTALUS system. RESULTS: Thirteen subjects that had completed 3 months of treatment showed a significant reduction in HbA1c from 8.0 +/- 0.2% to 6.9 +/- 0.1% (p < 0.05), whereas fasting blood glucose decreased from 175 +/- 6 mg/dL to 127 +/- 8 mg/dL (p < 0.05). The glycemic improvement was accompanied by reduction in weight from 104.4 +/- 4.4 kg to 99.7 +/- 4.8 kg, and in waist circumference from 122.3 +/- 3.2 cm to 117.0 +/- 3.0 cm. CONCLUSIONS: Interim results with the TANTALUS system suggest that this stimulation regime can potentially improve glucose levels and induce moderate weight loss in obese T2DM subjects on oral antidiabetic therapy with poor glycemic control. Further evaluation is required to determine whether this effect is due to induced weight loss and/or due to direct signal-dependent mechanisms.

Laparoscopic adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity. METHODS: A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies. RESULTS: No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery. CONCLUSION: Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

Intrapleural analgesia following thoracoscopic sympathectomy for palmar hyperhidrosis: a prospective, randomized trial.

BACKGROUND: Reports on intrapleural analgesia (IPA) are conflicting. The current study assessed the effect of a single-dose thoracoscopic bilateral intrapleural anesthetic administration on the immediate postoperative recovery room and 24-h pain control. METHODS: Fifty patients with primary palmar hyperhidrosis were randomly classified into two groups to receive either 20 ml of 0.5% bupivacaine and 5 mg/ml epinephrine or 0.9% NaCl in each thoracic cavity at the end of thoracoscopic T2-T3 sympathectomy. The degree of early postoperative pain was estimated by visual analog scale (VAS). The 24-h parenteral opioid analgesic requirement was recorded. RESULTS: The immediate postoperative VAS score (1.46 +/- 0.41 vs 2.0 +/- 0.61, p = 0.03), opioid consumption (0.42 +/- 0.36 vs 0.65 +/- 0.28, p = 0.0133), and 24-h opioid consumption (1.02 +/- 0.80 vs 1.48 +/- 0.84, p = 0.05) were significantly reduced following IPA compared to those of the control group. CONCLUSION: IPA is a simple and effective means for postoperative pain control following thoracoscopic upper dorsal sympathectomy.

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis. The use of harmonic scalpel versus diathermy.

BACKGROUND: Upper dorsal thoracoscopic sympathectomy, the treatment of choice for primary palmar hyperhidrosis, is not devoid of long-term complications, like Horner's syndrome and postoperative neuralgia. It has been postulated that propagation of heat induced by diathermy may be responsible for some of these sequelae. To assess this hypothesis, a study was undertaken to evaluate the use of harmonic scalpel, which does not dissipate heat. METHOD: Sixteen patients with primary palmar hyperhidrosis underwent upper dorsal thoracoscopic sympathectomy using the harmonic scalpel on one side and diathermy on the other. Follow-up was made two years postoperatively. RESULTS: The length of the procedure with each instrument was similar. There was no localization of postoperative pain, which could be attributed to either device. No Horner's syndrome or postoperative neuralgia occurred. CONCLUSION: The present study proved the safe use of harmonic scalpel for upper dorsal thoracoscopic sympathectomy, but did not detect any important advantage of either instrument over diathermy.

Impact of intraoperative sonography on resection and cryoablation of liver tumors.

PURPOSE: We retrospectively analyzed the impact of intraoperative sonography (IOUS) on the management of patients referred for resection of liver tumors. METHODS: Forty patients underwent IOUS with a 7-MHz curved-array sector transducer; in selected cases, a 5-MHz linear-array transducer attached to a color Doppler unit was also used. The number, size, and location of tumors on IOUS, including tumor proximity to or invasion of major vessels or invasion of the diaphragm, were compared to findings on preoperative imaging studies. The effect of these findings on surgical management was assessed. Unresectable lesions were treated by cryoablation under ultrasound guidance. RESULTS: IOUS detected preoperatively unsuspected lesions in 7 patients (18%). Metastases suspected on CT arterial portography were ruled out in 2 patients (5%), and indeterminate lesions were diagnosed as cysts by IOUS in 2 other patients (5%). Vascular proximity or vascular or diaphragmatic invasion detected by IOUS rendered lesions unresectable in 4 patients (10%). Cryoablation under IOUS guidance and monitoring was attempted in 11 patients (28%) and performed successfully in 10. CONCLUSIONS: IOUS changed the management in 38% of patients and guided cryoablation in 28% of patients. IOUS performed by an experienced sonologist is invaluable for the accurate assessment of liver tumor resectability; the detection of additional, preoperatively unknown lesions; and the guidance of cryoablation of unresectable tumors.

Thoracoscopic sympathectomy for palmar hyperhidrosis. Ablate or resect?

BACKGROUND: Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques. METHODS: A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis. RESULTS: In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017). CONCLUSIONS: Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.

Influence of hypertonic saline on bacterial translocation in controlled hemorrhagic shock.

Translocation of enteric bacteria has been described in rats following hemorrhagic shock (HS). The aim of the present study was to evaluate the effect of hypertonic saline (HTS) on bacterial translocation (BT) in the setting of controlled HS in rats. The study included 2 arms. Arm I was a qualitative assessment of translocation. Sixty-eight anesthetized animals were studied. The rats were divided into 5 groups. Group I (n = 10) was sham shock controls. In groups II-V, HS was induced by arterial bleeding to mean arterial pressure (MAP) of 35-45 mmHg, which was maintained for 30 min. The animals were then allocated into 4 groups: group II (n = 19) untreated HS; group III (n = 13) normal saline (NS) treated; group IV (n = 13) HTS-treated; and group V (n = 13) HTS and blood treated. Mesenteric lymph nodes, liver, spleen, portal, and systemic blood were sent for culture after 24 h. Translocation occurred if enteric bacteria were cultured from at least one site. Arm II was a quantitative assessment of translocation. Two groups were studied: untreated HS (n = 7) and HTS treated (n = 6). In the qualitative arm, the 24-h mortality in untreated rats (group II) was 31.5% compared to 5.1% in treated animals (groups II-V) (P = 0.01). No BT was detected in control animals (group I). BT after HS was not different between groups II, III, and IV (92.3%, 91.6%, and 100%, respectively). Group V showed fewer translocations than groups II-IV, a difference that was especially significant compared with group IV (P = 0.039). However, BT to distant sites (systemic blood and spleen) was significantly lower in group V than in groups II-IV (P < 0.05). In the quantitative arm, the mortality rate was 16.7% in the untreated group. Although no qualitative significant difference in the translocation rate was found between the two groups (67% in untreated animals vs. 50% in HTS treated), there was significant quantitative difference: in HTS-treated group a significantly lesser bacteria translocated than in untreated animals (0.4 x 10(5) cfu/g vs. 4.2 x 10(5) cfu/g, respectively [P = 0.001]). We concluded that whereas assessed qualitatively, in this model of severe HS in rats, the hemorrhagic insult itself resulted in BT in most animals and treatment with NS, HTS, and blood resulted in reduced early mortality but did not alter significantly the translocation rate. Only the combination of HTS and blood resulted in reduced BT to distant sites. However, quantitative assessment showed that HTS significantly reduced the number of translocating bacteria.

Transient chylous ascites following a distal splenorenal shunt.

The development of chylous ascites following abdominal surgery is an infrequent yet alarming complication. We present a patient in whom chylous ascites was diagnosed 6 days after a distal splenorenal shunt. Ten days following bed rest, sodium restriction, and a low-fat diet with medium-chain triglyceride supplementation the ascites resolved.

The effect of upper dorsal thoracoscopic sympathectomy on the total amount of body perspiration.

Thoracoscopic T2-T3 sympathectomy is the treatment of choice for primary palmar hyperhidrosis (PPH); however, compensatory hyperhidrosis (CH) is a disturbing sequela of this operation, the mechanism of which is poorly understood. This study was conducted to evaluate the effect of heat stress on total body perspiration after thoracoscopic T2-T3 sympathectomy, and determine its correlation with CH. A total of 17 patients with PPH who underwent bilateral T2-T3 sympathectomy were subjected to heat stress induced by a 10-min sauna bath (ambient temperature 70 degrees C), 1 day before and 1 month after surgery. The naked body weight was recorded before and immediately following the sauna bath, and the patients were followed up to assess whether CH had developed and the degree of its severity. Postoperatively, the amount of perspiration increased in 13 patients and decreased in 1. The amount of perspiration induced by the sauna bath ranged from 60 to 480 g, with a mean value of 185.29 +/- 125.80 g, before the operation, and from 60 to 540 g, with a mean value of 265.88 +/- 154.05 g, after the operation (P = 0.0113). There was no correlation between the degree of alteration in total body perspiration and the development of CH. Performing thoracoscopic T2-T3 sympathectomy for PPH affects the total body sweating response to heat; however, the development of CH does not correlate with this alteration.

The treatment of primary palmar hyperhidrosis: a review.

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.

Acute transient chylous ascites associated with acute biliary pancreatitis.

We report a case of acute chylous ascites secondary to acute biliary pancreatitis, the first such case reported in the literature. Surprisingly, chylous ascites was detected during elective cholecystectomy. The pathogenesis and management of this problem is discussed.

Thoracoscopic sympathectomy for hyperhidrosis: is there a learning curve?

The aim of this study was to evaluate the learning curve of upper dorsal thoracoscopic sympathectomy. From June 1993 to December 1996, we performed 232 sympathectomies on 116 patients with primary palmar hyperhidrosis. The T2-T3 ganglia were resected by electrocuting and were removed for histologic examination. The series was divided into two groups of 58 patients each, and operations in each group occurred during a period of 21 months. Follow-up was obtained on 111 patients for a mean of 25.06+/-12.62 months. All limbs were dry after the operation, and hyperhidrosis did not recur. The anesthesia time was reduced, but the operating time, the difficulty in identifying and in resecting the ganglia, compensatory hyperhidrosis, postoperative neuralgia, and subjective satisfaction with the procedure were similar in both groups. The learning curve in the present study was mainly reflected by a reduction in the incidence of Horner's syndrome.

Primary palmar hyperhidrosis presenting with unilateral symptoms: a report of two cases and review of the literature.

Two cases of primary palmar hyperhidrosis are presented. T2-T3 sympathetic ganglionectomy of the affected side completely alleviated perspiration of the palms, but oversweating of the contralateral palms appeared a few weeks later. A similar sympathetic ganglionectomy of the second side, 1 month and 1 year later, resulted in renewed oversweating of the palm on the first operated side within 3 months of the second operation. During the same period, 127 other patients with primary palmar hyperhidrosis underwent a bilateral upper dorsal sympathectomy, though the condition did not recur in any of these patients. The possible mechanism(s) of why overperspiration of the second hand developed after the first sympathectomy in these two patients, and why it recurred in the first hand after the second operation are examined, but remain obscure.

[Combined treatment of hepatic tumors by cryosurgery and resection: first results].

Cryosurgery is an old technique which is being used for hepatic tumors as an adjuvant to hepatic resection. We recently treated 7 patients with multiple malignant liver tumors, 5 of whom had colorectal metastases, 1 carcinoid metastases, and 1 multiple hepatic lesions of hepatocellular carcinoma. 6 underwent combined liver resection and cryoablation of lesions in the remaining liver. In the 7th patient, only cryoablation was performed because hepatic resection was rejected and there was an extrahepatic metastasis. The advantages of this treatment are removal or destruction of all liver lesions found by any method, including intraoperative ultrasound examination, maximal preservation of normal liver parenchyma and that it is curative in patients inoperable by standard criteria.

Emergency minilaparotomy cholecystectomy for acute cholecystitis: prospective randomized trial--implications for the laparoscopic era.

This prospective controlled trial evaluates the efficacy of minicholecystectomy (MC) in cases of acute cholecystitis compared to that of conventional cholecystectomy (CC) and discusses its implications in the laparoscopic era. Sixty consecutive patients with acute cholecystitis were prospectively randomized into two groups: MC group (30 cases) and CC group (30 cases). The two groups were well matched with regard to age, sex, weight/height index, previous upper abdominal surgery, and APACHE II scores. The mean length of incision was 5.5 cm (range 4.5-9.0 cm) in the MC group compared to 13.5 cm (range 12-16 cm) in the CC group. No significant differences were found between MC and CC with regard to operative time (69.1 +/- 17.0 and 68.1 +/- 15.4 minutes, respectively; p = 0.82), operative difficulty on a 1 to 10 scale (5.2 +/- 1.5 versus 4.6 +/- 1.6, respectively; p = 0.177), and complication rate (11% and 17%, respectively; p = 0.19). Significantly lower analgesia requirements were noted in the MC group: 27.5 +/- 14.6 mg of morphine sulfate compared to 44.5 +/- 13.2 mg in the CC group (p < 0.001). In addition, the duration of hospital stay was significantly shorter for MC patients (3.1 +/- 1.0 days) than in CC patients (4.7 +/- 1.2 days) (p < 0.001). Twenty-two patients (73.3%) in the MC group were reported to return to normal daily activities 2 weeks after the operation, compared to only 12 (40%) in the CC group (p = 0.0028). MC is safe and applicable as an emergency procedure for acute cholecystitis. It is superior to CC in terms of convalescence and cosmesis. The results of MC in the setting of acute cholecystitis compare favorably with the published results of laparoscopic cholecystectomy.

[Gastrografin for mechanical partial, small bowel obstruction due to adhesions].

The therapeutic effect of gastrografin is occasionally mentioned in the literature. However, this effect has not been objectively evaluated. We studied prospectively the effect of Gastrografin in cases of adhesive, simple, partial, small bowel obstruction (SBO) compared to conventional management. During 3 years, a total of 137 episodes of simple, partial SBO in 127 patients (10 recurrent episodes) were treated. The episodes were randomized into a control group (80 episodes), treated conventionally, and a trial group (77 episodes), which received in addition 100 ml of Gastrografin administered through the nasogastric tube. The two groups were well-matched with regard to age, gender, weight, medical and surgical background and duration of complaints before admission. Time to first stool and resolution of obstruction, complications, need for surgery, and hospital stay were noted. Mean time to first stool was significantly shorter in the trial group: 6.2 +/- 3.9 hours vs 23.5 +/- 12.7 (p < .0001). Mean hospital stay for unoperated patients was also shorter in the trial group: 2.7 +/- 2 days vs 5.5 +/- 2 days, (p < .0001). In addition, significantly fewer episodes in the trial group required operation, 10.4 vs 26.7% (p < 0.013). 1 patient in each group dies following operation. There were no Gastrografin-related complications and it was effective and safe for adhesive, partial, simple SBO. It significantly speeds resolution of obstruction, reduces the need for operation, and shortens convalescence.