Division of the short gastric vessels during laparoscopic Nissen fundoplication: clinical and functional outcome during long-term follow-up in a prospectively randomized trial.

BACKGROUND: Although the first laparoscopic Nissen fundoplication was performed almost two decades ago, division of the short gastric vessels is still controversially discussed. The aim of this prospectively randomized trial was to evaluate the clinical and functional outcome following laparoscopic Nissen fundoplication with division versus saving of the short gastric vessels during short- and long-term follow-up. METHODS: Forty-one consecutive patients (30 men, 11 women) with gastroesophageal reflux disease were allocated to undergo Nissen fundoplication without division (group 1, n = 19) or with division (group 2, n = 22) of short gastric vessels. All patients were evaluated prior to and at 6 months as well as 5 years following fundoplication. Tests included endoscopy, barium swallow, 24-h pH monitoring, and esophageal manometry. Gastroesophageal reflux disease (GERD) symptoms were evaluated and a gastrointestinal quality-of-life index was calculated. RESULTS: Preoperative symptoms such as heartburn (84/86%), regurgitation (79/86%), pulmonary symptoms (47/45%), dysphagia (11/32%), chest pain (16/9%), and globus sensation (21/27%) were seen in groups 1 and 2, respectively. In group 1 regurgitation and mild dysphagia were seen in 7 and 26% of patients, respectively, at 5 years. In group 2 the rate of dysphagia decreased from 32 to 17% during short-term follow-up, but increased thereafter to 18%. Reflux esophagitis (preoperative rates: group 1, 74%; group 2, 59%) disappeared in all patients after fundoplication. Mean operative time (group 1, 109 min versus group 2, 125 min; p < 0.05) and mean blood loss (group 1, not measurable; group 2, 25 ml; p < 0.05) showed statistically significant differences. DeMeester score improved in group 1 from 26.6 to 2.2 and in group 2 from 24.7 to 2.5 at 5-year follow-up (p = 0.02). Lower esophageal sphincter (LES) resting pressure returned to normal values (group 1, 23.9 mmHg; group 2, 24.6 mmHg; p < 0.007) with regular relaxation. Quality-of-life index was high in both cohorts, without statistically significant differences between the two groups. CONCLUSION: Routine division of the short gastric vessels during Nissen fundoplication in the followed patient group yields neither functional nor clinical advantages in short- or long-term follow-up.

DaVinci robotic-assisted laparoscopic bariatric surgery: is it justified in a routine setting?

BACKGROUND: Laparoscopic silicone adjustable gastric banding (SAGB) has gained popularity for the surgical treatment of morbid obesity. The implantable gastric stimulator (IGS) system represents a novel surgical alternative. We aimed to assess the feasibility of robotic-assisted laparoscopic bariatric operations and to critically elucidate the technical and financial advantages and patient outcome. METHODS: Robotic-assisted laparoscopic bariatric procedures were performed on 10 consecutive patients using the daVinci robot system (4 SAGB, 4 IGS, 2 SAGB revisions). 10 conventional laparoscopic-operated patients (4 SAGB, 4 IGS, 2 SAGB revisions) during the learning curve served as controls. Equipment, operative technique and procedural time were evaluated. A cost analysis was calculated. RESULTS: The personnel equipment, numbers of trocars and operation technique were comparable in both groups. The mean operative time was 137 min (range 110-175) and 97 min (60-140) in robotic-assisted and conventional laparoscopy, respectively (P =0.04). Establishment of the pneumoperitoneum and placement of trocars and robotic arms took a mean of 30 min (15-45) in the robotic-assisted group, compared with 5 min in the control group (P <0.001). In 1 patient, intraoperative gastric injury was suspected and led to band removal in the robotic-assisted group. There was no postoperative complication. Average procedural costs were significantly higher in the robotic-assisted group. CONCLUSION: Primary and revisional robotic-assisted bariatric surgery is technically simple, with the benefit of precise instrument handling. However, it is still expensive, the set-up of the system is time-consuming, and a limited variety of instruments are available presently.

[Restrictive procedures in the treatment of morbid obesity -- vertical banded gastroplasty vs. adjustable gastric banding]. / Gastrorestriktive Operationstechniken zur Behandlung der morbiden Adipositas -- Vertikale bandverstärkte Gastroplastik vs. bandverstellbare Gastroplastik.

Vertical banded gastroplasty (VBG) has been in clinical use since 1979 and the adjustable gastric banding (AGB) since 1985. The aim of this study was to compare the outcome, short- and long-term complications of the two procedures. Within a period of 9 years (1992-2001) 1 011 gastric restrictive procedures were performed by two surgeons in the course of a prospective nonrandomized comparative trial. 563 VBG's via laparotomy and 448 laparoscopic AGB's were included into the study. The mean BMI of the patients was 46 kg/m 2 in both groups. The mean duration of follow up was 60 months (range 6 to 108 months). No statistical significant difference in outcome in terms of weight loss, reduction of co-morbidity and improvement in quality of life following ASGB or VBG was observed. The hospital mortality rate was 0.3 % (2 VBG, 1 AGB). The overall reintervention rate for long-term complications was 15.6 % for the VBG and 7 % for the AGB group (p < 0.0001). The AGB is entirely reversible and the less invasive procedure preserving an intact anatomy of the stomach. A trend in favour of the AGB is observed.

[Intragastric stimulation (IGS) for treatment of morbid obesity]. / Intragastrale Stimulation als erste nichtrestriktive und nichtmalabsorptive Behandlungsmethode der morbiden Adipositas.

The technique of implantable gastric stimulator (IGS(R)) placement for treatment of morbid obesity is described. There are three components of the IGS, the programming system, the lead and the electrical stimulator itself. It is placed in the anterior abdominal wall. It is connected to the bioplar lead that is positioned in the muscle wall of the stomach. The nominal parameters were: pulse width 208 micro sec 24 hours per day, pulse rate 40 Hertz and amplitude 6.2-10.0 mA. Fourty eight patients have been treated using techniques that were developed and refined around the world in a prospective open study. 32 and 7 patients, resp. were available for investigation after 6 and 15 months. Twenty-seven (56 %) intra-operative gastric penetrations occurred, as noted on operative gastroscopy, without any clinical sequelae. Six patients (12 %) showed lead dislodgements and a new procedure for lead replacement. There were no operative deaths. All procedures were successfully completed laparoscopically. Two connections required revision (4 %) because the leads were not fully inserted into the lead connector of the generator. No abscess formation or severe complication were noted. The excessive weight loss after 15 months ranged to 32 %. The operation for IGS placement is safe and simple to perform. Attention to technical details is essential for safe performance of the procedure.