The short- to mid-term symptom prevalence of dumping syndrome after primary gastric-bypass surgery and its impact on health-related quality of life.

BACKGROUND: Early and late dumping are complications of gastric bypass surgery. Early dumping occurs within an hour after eating, when the emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and the release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs between 1 and 3 hours after carbohydrate ingestion and is caused by an exaggerated insulin release, resulting in hypoglycemia. Almost no data are currently available on the prevalence of early and late dumping or their impact on health-related quality of life (QoL). OBJECTIVES: To study the prevalence of early and late dumping in a large population of patients having undergone a primary Roux-en-Y gastric bypass (RYGB) and its effect on QoL. SETTING: Cross-sectional study at a single bariatric department in the Medical Center Leeuwarden, The Netherlands between 2008 and 2011. METHODS: In 2013, this descriptive cohort study approached by email or post all patients who underwent a primary RYGB in the setting between 2008 and 2011 in one hospital. These patients were asked to fill in standardized questionnaires measuring their QoL (RAND-36), anxiety and depression (HADS), fatigue (MFI-20) and any disease specific indicators of early and late dumping syndrome. RESULTS: The questionnaire was completed and returned by 351 of 613 patients (57.1%) and 121 nonobese volunteers. Participants were mostly female (80%), aged 42 (40-54 years), with an excess weight loss of 76.8% [IQR 61-95] after RYGB surgery 2.3 [ IQR 1.6-3.4] years earlier. Self-reported complaints of moderate to severe intensity suggestive of early and late dumping were present in 18.8% and 11.7% of patients, respectively. Patients with early and late dumping demonstrated significantly lower scores on the RAND-36 and HADS compared with patients without dumping. No differences were seen in the MFI-20 scores between patients with or without early and late dumping. CONCLUSION: In this descriptive cohort, self-reported complaints suggestive of early and late dumping of moderate-to-severe intensity were, respectively, 18.8% and 11.7% in a cohort after primary gastric bypass surgery. These complaints were associated with markedly reduced health-related QoL.

Ergonomic assessment of the French and American position for laparoscopic cholecystectomy in the MIS Suite.

BACKGROUND: Cholecystectomy was one of the first surgical procedures to be performed with laparoscopy in the 1980s. Currently, two operation setups generally are used to perform a laparoscopic cholecystectomy: the French and the American position. In the French position, the patient lies in the lithotomy position, whereas in the American position, the patient lies supine with the left arm in abduction. To find an ergonomic difference between the two operation setups the movements of the surgeon's vertebral column were analyzed in a crossover study. METHODS: The posture of the surgeon's vertebral column was recorded intraoperatively using an electromagnetic motion-tracking system with three sensors attached to the head and to the trunk at the levels of Th1 and S1. A three-dimensional posture analysis of the cervical and thoracolumbar spine was performed to evaluate four surgeons removing a gallbladder in the French and American position. The body angles assessed were flexion/extension of the cervical and thoracolumbar spine, axial rotation of the cervical and thoracolumbar spine, lateroflexion of the cervical and thoracolumbar spine, and the orientation of the head in the sagittal plane. For each body angle, the mean, the percentage of operation time within an ergonomic acceptable range, and the relative frequencies were calculated and compared. RESULTS: No statistical difference was observed in the mean body angles or in the percentages of operation time within an acceptable range between the French and the American position. The relative frequencies of the body angles might indicate a trend toward slight thoracolumbar flexion in the French position. CONCLUSION: In a modern dedicated minimally invasive surgery suite, the body posture of the neck and trunk and the orientation of the head did not differ significantly between the French and American position.

Early learning effect of residents for laparoscopic sigmoid resection.

OBJECTIVE: To evaluate the effect of learning the laparoscopic sigmoid resection procedure on resident surgeons; establish a minimum number of cases before a resident surgeon could be expected to achieve proficiency with the procedure; and examine if an analysis could be used to measure and support the clinical evaluation of the surgeon's competence with the procedure. DESIGN: Retrospective analysis of data which was prospective entered in the database. PARTICIPANTS: From 2003 to 2007 all patients who underwent a laparoscopic sigmoid resection carried out by senior residents, who completed the procedure as the primary surgeon proctored by an experienced surgeon, were included in the study. A cumulative sum control chart (CUSUM) analysis was used evaluate performance. The procedure was defined as a failure if major intra-operative complications occurred such as intra abdominal organ injury, bleeding, or anastomotic leakage; if an inadequate number of lymph nodes (<12 nodes) were removed; or if conversion to an open surgical procedure was required. RESULTS: Thirteen residents performed 169 laparoscopic sigmoid resections in the period evaluated. A significant majority of the resident surgeons were able to consistently perform the procedure without failure after 11 cases and determined to be competent. One resident was not determined to be competent and the CUSUM score supported these findings. CONCLUSIONS: We concluded that at least 11 cases are required for most residents to obtain necessary competence with the laparoscopic sigmoid resection procedure. Evaluation with the CUSUM analysis can be used to measure and support the clinical evaluation of the resident surgeon's competence with the procedure.

Functional imaging in hyperinsulinemic hypoglycemia after gastric bypass surgery for morbid obesity.

CONTEXT: Hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass (RYGB) has been increasingly reported. It is induced by ß-cell hyperplasia often referred to as nesidioblastosis. Positron emission tomography (PET) with [11C]-5-hydroxytryptophan ((11)C-HTP) and 6-[18F]fluoro-3,4-dihydroxy-l-phenylalanine ((18)F-DOPA) has been successfully applied to image neuroendocrine tumors. No data are available of the usefulness of these functional imaging techniques in post-RYGB in this new endocrine disorder, neither for diagnostic purposes nor for follow-up. OBJECTIVE: We present a patient with post-RYGB hypoglycemia who underwent (11)C-HTP and (18)F-DOPA PET scintigraphy for diagnostic purposes and to evaluate the effect of additional laparoscopic adjustable banding of the pouch as a surgical therapy for this disorder. PATIENT: We describe a woman with biochemically confirmed post-RYGB hypoglycemia who showed diffuse uptake of the (11)C-HTP and (18)F-DOPA tracers in the entire pancreas. After failure of dietary and medical treatment options, she underwent a laparoscopic adjustable banding for pouch dilatation. Subjective improvement was noted, which coincided with decreased uptake of (18)F-DOPA and (11)C-HTP in the head of the pancreas. CONCLUSIONS: Functional imaging by (18)F-DOPA- and (11)C-HTP-PET can accurately visualize diffuse endocrine pancreatic activity in post-gastric bypass hyperinsulinemic hypoglycemia. Both (11)C-HTP- and (18)F-DOPA-PET imaging appear to have a similar diagnostic performance in the presented case, and uptake of both tracers potentially relates to disease activity after surgical intervention.

Effect of proctoring on implementation and results of elective laparoscopic colon surgery.

PURPOSE: A steep learning curve exists for surgeons to become skilled in laparoscopic colon resection. Our institute offers a proctored training programme. The purpose of this descriptive study was to evaluate whether the course resulted in adoption of laparoscopic colorectal surgery into clinical practice, explore post-course practice patterns and analyse the outcome of surgical performance. METHODS: Between 2003 and 2008, 26 surgeons were trained by our institute. The course consisted of 24 elective laparoscopic resections under direct supervision. A questionnaire and a prospective post-course web-based registration were used to analyse the effect of the training and the outcome of surgical performance. RESULTS: The response rate of the questionnaire was 85%. The majority had not performed any laparoscopic colon resections before attending the course. All 24 respondents successfully implemented laparoscopy into daily practice. After the course, 70% of all sigmoid resections were performed laparoscopically in contrast with 0% of all transverse colon resections. The results of the trainees after following the course are equal to results of other studies. CONCLUSIONS: A proctored training programme, consisting of 24 supervised cases, is safe and feasible. For adequate monitoring, participating in a post-course registry should be obligatory.

The laparoscopically harvested omental flap for deep sternal wound infection.

OBJECTIVE: To report our experience with the laparoscopically harvested omental flap in the treatment of deep sternal wound infection, and to present a modification and introduce two supportive techniques in the perioperative management. METHODS: Between June 2005 and September 2007, six patients with grade IV (El Oakley-Wright classification) deep sternal wound infection following a median sternotomy for coronary artery bypass grafting underwent a reconstruction with a laparoscopically harvested omental flap. The median age of the cohort of six, consisting of one female and five males, was 67 years (range: 61-77 years). In five patients, an unilateral internal thoracic artery had been used. Considerable preoperative risk factors were present: one patient suffered from severe chronic obstructive pulmonary disease (COPD) Forced expiratory volume in 1s (FEV1)1L; two from moderate chronic obstructive airway disease, three from insulin-dependent diabetes mellitus and three were on glucocorticoid steroid therapy preoperatively. Abdominal surgery had previously been performed in four patients. In all cases, the mediastinal wound was prepared with vacuum-assisted (

A technique for prevention of port complications after laparoscopic adjustable silicone gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding is a safe and effective treatment method for morbid obesity. Injection port dislocation, tube perforation and access port infection are generally classified among the minor complications, although they can require a reoperation at the port-site or even at the level of the band which may have to be removed. We designed a technique to fix the port, that can avoid unnecessary complications. METHODS: The port is sutured onto a polyprophlene mesh, which is then cut into shape and attached to the rectus fascia in the left hypochondrium with a Tacker stapling device. From February 2000 to January 2001, 25 patients (BMI 35-60) were operated using this technique. RESULTS: No injection port dislocation, tube perforation or access port infection has been found in these patients. CONCLUSION: With the larger surface area by which the port is attached to the fascia, a stable position of the port is obtained and dislocation avoided. Multiple failed attempts at port access, with resulting risk of infection, are avoided. Due to port stability, risk of incidental tube perforation is reduced. Moreover, a considerable gain of time is obtained compared with the classical suturing of the port.