The progress in bariatric surgery.

Morbid obesity, caused by fat tissue accumulation, is a serial multi-factorial chronic disease, with rapidly increasing prevalence in most countries in the world including Poland. Conservative treatment of morbid obesity is almost always unsatisfactory and that is why several surgical methods have been developed. There are four kind of methods: malabsorbtive procedures; restrictive procedures; malabsorbtive/restrictive procedures and experimental procedures. The development of bariatric surgery goes back to 1952 and since that time it has been evolving dynamically. All the surgical methods have benefits and disadvantages. Presently the introduction of minimally invasive surgical techniques seems to be very safe, efficient and cost-effective in treatment for morbid obesity. New methods are also being evaluated, such as gastric myo-electrical stimulation. Bariatric surgery will still be developing until we understand all the factors responsible for it is origin.

The nasal airway evaluation in morbid obesity.

The aim of the present study was to evaluate objectively the nasal patency in the obese patients. A total of 18 morbidly obese patients were recruited for the study. All of them were surgically treated because of morbid obesity using Bilo-Pancreatic Diversion (BPD) or Laparoscopic Gastric Banding (LGB) methods. The patients were free of nasal abnormalities, such as septum deviation, polyps, nasal concha hypertrophy and paranasal sinus diseases. This group comprised 10 men and 8 women aged from 17 to 54. The mean Body Mass Index (BMI) was 51.6 kg/m(2), ranged from 34.7 to 61.8 kg/m(2). In all of the patients the nasal patency was examined by active anterior rhinomanometry according International Standardization Rhinomanometric Committee using air pressure 75, 100 and 150 dPa. The results were compared to the healthy control group. The correlation between BMI and nasal airflow pressure was also examined. We found that inspiration values for 75, 100 and 150 dPa as well as the expiration values for 100 and 150 dPa in standard method and expiration values for 100 and 150 dPa in Broms method using anterior rhinomanometry in morbidly obese patients were statistically significant higher in comparison with the healthy controls. No statistical significant correlation between BMI of obese patients and the airflow pressure values was found. We conclude that in the morbid obesity the nasal patency is reduced as compared to the healthy controls.

Biliopancreatic diversion in Poland.

Biliopancreatic diversion (BPD) is a bariatric operation of proved efficacy especially in patients with metabolic comorbidities. The aim was to assess the results of BPD in relation to weight loss and coexisting lipid and glucose metabolism disturbances in the Polish population. Between October 2001 and December 2003 57 morbidly obese patients (24 male and 33 female) underwent BPD. Median age was 46 years (range: 17-58) and median body mass index (BMI) was 50.2 kg/m(2) (range: 40.1-73 kg/m(2)). Type 2 diabetes mellitus was observed in 11 patients (19.3%), hypercholesterolaemia in 38 patients (66.7%) and hypertriglyceridaemia in 37 patients (64.9%). Median value of BMI decreased at three months to 40.0 kg/m(2), at six months to 36.7 kg/m(2), and after a year to 32.3 kg/m2. Diabetes was completely resolved in all patients. After six months, triglycerides and cholesterol levels were higher than normal only in one patient. Early specific complications that manifested as seroma and nosocomial pneumonia occurred in 5.3% and 3.5% patients, respectively. The following specific late complications were observed: ulceration of stomach stump (3.4%), anaemia (14.0%), hypoalbuminaemia (8.8%), deterioration of haemorrhoids (15.8). All of above complications were treated conservatively expect two haemorrhoidectomies. One patient died due to myocardial infarction eight months after BPD. Five cases of incisional hernias (8.8%) were found. BPD is an effective bariatric procedure also in the Polish population, resulting not only in weight loss but also in the improvement of lipid and glucose metabolism.

Results of revisional operation following vertical banded gastroplasty performed due to morbid obesity--comparison between restoration of vertical banded gastroplasty and conversion of gastric bypass up to three years.

The aim of this study was to analyse incidence and efficacy of revisional surgery for failed vertical banded gastroplasty among 458 patients who underwent primary surgery between 1993 and 2003. Staple line disruption was diagnosed in 29 patients and was an indication for restoration of gastroplasty in 10 cases and a conversion to Roux-en-Y gastric bypass in 19 patients. In two cases of outlet stenosis the band was exchanged to enlarge the collar. In two cases of psychological intolerance of restriction the band was removed because of refusion by patients the conversion to Roux-en-Y gastric bypass. A substantial weight reduction without statistical differences between restoration and conversion group was recognized. In two patients (20%) after restoration and three patients (15.8%) after conversion we observed weight regain (p=0.57). In cases with removed band weight regained up to its value recorded before surgery. In patients with exchanged band weight was under control. No serious complications were observed. We could conclude that patients with weight regain after vertical banded gastroplasty should be offered conversion to Roux-en-Y gastric bypass. When malabsorption is refused, restoration of vertical banded gastroplasty could be also performed. Both of procedures are technically difficult but safe.

[Plasma oxysterols and vitamin E concentrations and lipid profile in morbidly obese women]. / Stezenie oksycholesteroli i witaminy E a profil lipidowy osocza u kobiet ze skrajna otyloscia.

Morbid obesity (BMI > or = 40 kg/m2) is accompanied by lipid disturbances which may be involved in the increased incidence of atherosclerosis, arterial hypertension and non-insulin-dependent diabetes mellitus. The aim of the study was to assess concentrations of total cholesterol (TC), HDL-cholesterol, LDL-cholesterol, triglycerides (TG), products of cholesterol peroxidation--oxysterols, and the major lipophilic antioxidant--vitamin E, in morbidly obese women without coexisting diseases. The study was performed in 11 morbidly obese women (BMI 42.21 +/- 2.21 kg/m2) and 11 healthy volunteers (BMI 23.0 +/- 2.31 kg/m2). Obese women demonstrated higher concentrations of TG (2.03 +/- 0.78 vs. 0.99 +/- 0.37 mmol/l; p < 0.05), 7-ketocholesterol (7-K) (89.85 +/- 63.03 vs. 41.90 +/- 17.33 ng/ml; p < 0.05) and 7-hydroxycholesterol (7-OH) (456.04 +/- 199.22 vs. 132.37 +/- 53.96 ng/ml; p < 0.05), and lower HDL-cholesterol level (0.74 +/- 0.10 vs. 1.30 +/- +/- 0.17 mmol/l; p < 0.05) compared to the control group, while there were no significant differences between the two groups in concentrations of TC, LDL-cholesterol and vitamin E. Plasma vitamin E/(TC + TG) ratio was lower in obese women (6.42 +/- 2.61 vs. 10.76 +/- 4.57 mumol/mmol; p < 0.05). Tocoferols concentration correlated positively with TG (r = 0.45; p < 0.05) and negatively with 7-OH (r = -0.44; p < 0.05) levels. Moreover, concentration of 7-K correlated positively with the level of HDL (r = 0.54; p < 0.05). In conclusion, despite normal TC and LDL-cholesterol concentrations, there are disturbances in cholesterol peroxidation processes, with the rise in oxysterol levels and the decrease in vitamin E concentration in lipoproteins, which may be involved in the increased incidence of cardiovascular diseases in morbidly obese women.

Swedish adjustable gastric band (SAGB) implanted laparoscopically in the treatment of morbid obesity--the first experience in Poland.

Surgical treatment of morbid obesity is a recognized method of proceedings in patients who did not obtain any positive results in conservative therapy. In October and November 1998 laparoscopic implantation of the SAGB was performed among ten morbid obesity patients with mean BMI of 41.9 +/- 3.6 kg/m2. It was the first experience in Poland. In this group we observed also non-insulin dependent diabetes mellitus in five, hyperlipidemia in eight and hypertension in three patients. In this series, there was no mortality and no perioperative morbidity. The mean operation time was 158 +/- 51 min. The mean hospital stay was four days after the operation. Median BMI reduction after four months was 4.7 +/- 1.6 kg/m2. Parallel to the reduction in body weight, there occurred a significant reduction in plasma concentration of glucose (111.0 +/- 38.5 vs. 90.2 +/- 20.8 p < 0.01), total cholesterol (223.8 +/- 42.0 vs. 192.7 +/- 21.3 p < 0.005), and LDL-cholesterol (140.4 +/- 34.0 vs. 121.7 +/- 25.2 p < 0.01). Hypertension was still observed only in one patient. Nowadays laparoscopic gastric banding represents the least invasive surgical treatment of morbid obesity. In our series laparoscopic implantation of SAGB seems to be an effective surgical method for the treatment of obesity. Substantial reduction in body weight was associated with improvement in metabolic control. Absence of mortality and morbidity is one of the main aims in bariatric surgery which was achieved in our study. The results of the present, first in Poland, preliminary study confirm previous observations that gastric banding is an effective treatment of obesity.

Circadian variations of androstenedione, dehydroepiandrosterone sulfate and free testosterone in obese women with menstrual disturbances.

OBJECTIVE: To assess the 24 h profile of androgenemia related to the androgens of both the ovarian and adrenal origin in obese women with menstrual disturbances. METHODS: The association of body mass and body fat distribution with circadian variations of selected androgens of ovarian and adrenal origin was examined in 16 obese women with menstrual disturbances (BMI between 38 and 51 kg/m2; WHR between 0.80 and 0.99) and in 16 healthy volunteers with normal body weight (BMI between 21 and 24.6 kg/m2; WHR between 0.73 and 0.76). The age range of all subjects was 29 to 40 (mean: 36.9+/-3.2 years). RESULTS: lts. Both the patients and control subjects showed a significant 24 h rhythm of androstenedione (A) and free testosterone (FT), while the circadian oscillations of dehydroepiandrosterone sulphate (DHEAS) did not differ significantly. In all obese women mean 24 h A, DHEAS and FT levels were significantly higher than those in controls. Moreover, the disturbances of DHEAS and FT secretion in the form of acrophase shift (for DHEAS from 7.37 to 3.45 h and for FT from 6.04 to 3.31 h) and the elevation of their 24 h amplitude values were observed. All obese women showed higher values of FT/A and FT/DHEAS indexes in selected clock time of day/night cycle (except those at 8.00 h for FT/A and at 5.00 h for FT/DHEAS) when compared to control group. A positive correlation was noted in all women studied between the values of BMI index, WHR ratio and mean 24 h level of androgens studied as well as FT/A and FT/ DHEAS indexes. A weaker correlation was found between body mass and body fat distribution on the one hand and fasting level of hormones studied on the other. Higher correlation between the values of WHR ratio and mean 24 h FT levels as well as FT/DHEAS indexes were obtained in obese women when compared to those of healthy subjects. CONCLUSIONS: Our findings suggest that, when assessing the androgen disturbances in obese patients, it is more useful to determine their circadian pattern than the basal level. The most reliable indicators of hyperandrogenism in obese women are: the 24 h concentration profile of FT and the value of FT/DHEAS index, not only during fasting but also after a meal at various time intervals. Circadian FT concentration and FT/DHEAS index values are essential indicators for visceral distribution of adipose tissue.

Assessment of bone metabolism in obese women.

OBJECTIVE: To evaluate the bone metabolism in obese women by the estimation of selected markers of bone formation. METHODS: The concentration of plasma parathyroid hormone (PTH) and selected markers of bone formation [osteocalcin (BGP) in plasma, carboxyterminal propeptide of type I procollagen (PICP) and alkaline phosphatase (AP) activity in blood serum] and bone resorption [cross-linked carboxyterminal telopeptide of type I collagen (ICTP) in blood serum and urinary excretion of calcium (Ca)] in 18 extremely obese women (BMI>40 kg/m2) with android phenotype (WHR>0.8) and in 20 healthy women with normal body weight. The age range of all subjects was 25 to 42 years (mean: 36.82 + 3.95). RESULTS: All obese women showed significantly increased concentration of plasma PTH, BGP and serum PICP, ICTP and elevated urinary excretion of Ca. CONCLUSIONS: The obtained results show that in extremely obese women with android phenotype bone metabolism disturbances may occur pointing at increased bone formation and resorption.

[Contemporary methods of treatment of morbid obesity]. / Wspólczesne metody leczenia skrajnej otylosci.

Surgical treatment of morbid obesity appears to be more cost-effective than medical treatment. Moreover many medical treatments fail in the long term especially in cases with BMI > 40 kg/m2. That's why surgical treatment was introduced. Two kinds of procedures, gastric restrictive and gastric bypass, have resulted from these years of clinical investigation. Mentioned above surgical treatment produce efficient weight loss during several months after operations. Weight reduction surgery has been reported to improve several comorbid conditions. Minimal invasive procedures are waiting for randomised studies.

Assessment of the relationship between collagen metabolism and selected hormonal factors in extremely obese women before and after jejunoileostomy.

The majority of obese persons have hyperinsulinemia and disturbances in the secretion of melatonin, catecholamines and pituitary, thyroid, adrenal and gonadal hormones. These hormones play an important role in the regulation of collagen metabolism either by acting directly or by influencing IGF-I production. This study aimed at ascertaining whether, and to what degree, the changes in the concentration of hormones listed above as well as in the concentration of sex hormone-binding globulin (SHBG) and insulin-like growth factor-I (IGF-I) affect the metabolism of collagen as evaluated indirectly from the measurement of propeptides of type I (PICP) and type III procollagen (PIIINP) in blood serum and hydroxyproline in urine. The study compared 30 women with extreme obesity before and three to five years after jejunoileostomy with 20 healthy women of reproductive age. All non-operated obese women showed significantly increased concentration of serum insulin, IGF-I, melatonin, norepinephrine, free triiodothyronine, estradiol, total and free testosterone, PICP, PIIINP and urinary excretion of hydroxyproline, while the levels of epinephrine, progesterone and SHBG were significantly decreased. Changes in the level of the examined markers of collagen metabolism correlated positively with the concentration of insulin, IGF-I and sex hormones, while the correlation with epinephrine, cortisol and thyroid hormones was negative. All women who were treated previously by jejunoileostomy showed a decreased of body mass to regular values, normalization of hormonal disturbances and normal collagen metabolism. The obtained results show that the increased collagen metabolism observed in extremely obese women is caused indirectly by altered endocrine activity.

[Causes of peri-operative mortality in patients with esophageal cancer treated surgically (personal material)]. / Przyczyny smiertelnosci okolooperacyjnej chorych z rakiem przelyku leczonych operacyjnie (material wlasny).

99 surgical procedures of thoracic part of esophagus resections were performed between 1985 and 1995. All thoracotomies were right-sided and alimentary canal continuity were substituted with a stomach (or with a small intestine or a colon in only a few cases) transposed inside a thorax cavity. Almost all cases there were planoepitheliale cancers. The sex index (men to women) was 6:1. The main reason of perioperative mortality were pulmonary complications (almost 90%): a respiratory insufficiency, an atelectasias, infections, and a broncho-pleural leakage. The nutrition state, stapler-using, anastomosis leak, and wound-healing way had no influence on mortality rate. Other mortality reasons there were a pleural hemorrhage, a mediastinitis as a result of esophago-gastric anastomosis disruption, a heart infarct, and a thrombo-embolic complications.

[The role of Shouldice's operation in treating inguinal hernia]. / Miejsce operacji Shouldice a w leczeniu przepukliny pachwinowej.

Clinical estimation of Shouldice procedure in the surgical treatment of inguinal hernia was performed in the group of 95 patients (102 operations) treated in the Second Department of General and Vascular Surgery Clinic at Zabrze between 1994 and 1996. Their ages ranged from 18 to 78 years with an average 53.6. The sex index (men to women) was 11:1. The bilateral hernia was found in seven cases and all of them were treated surgically at the same time. The most treated hernias was considered as type II and V by Gilbert classification. Among treated patients there were six cases of recurrence hernia earlier operated according to other procedures (mainly Bassini, Girard, Halsted, and artificial knitted-graft placed up intraperitoneally). In 28 cases of fascia transversalis large deficiency (the third and fourth type of Gilbert classification) authors used the two-layer modification method of reconstruction instead four layer of hernial canal posterior wall reconstruction the typical for Shouldice procedure. It was sufficient in all cases without respect to hernia size and fascia transversalis deficiency. There were no complications in postoperative periods. The recurrence of hernia, appeared only in one patient (0.98%) nine months after operation. In authors opinion, the Shouldice procedure is the most effective among all classical ways of inquinal hernia repairs.

[A case of ectopic breast tissue located in the axilla]. / Przypadek tkanki gruczolu sutkowego ektopowo zlokalizowanej w dole pachowym.

Authors have presented a very rare case of young woman favourable surgically treated for morphologically correct breast tissue in the unilateral axilla. They have paid the peculiar attention to possibility of ectopically placed breast tissue malignancy of every that case.

ASSESSMENT OF BETA-ENDORPHIN AND MELATONIN CIRCADIAN RHYTHMS IN NORMOTENSIVE OBESE WOMEN OF REPRODUCTIVE AGE.

We have evaluated the relationship between beta-endorphin (beta-EP) and melatonin (MEL) secretion as determined at 3 h intervals over a 24 h period in 27 normotensive obese women of different phenotypes (12 showing gynoid-type and 15 showing android-type of adipose tissue distribution) as well as in 12 healthy volunteers with normal body weight, aged 30 to 40 years. A considerable increase of mean 24 h beta-EP secretion (mainly due to elevated afternoon and evening levels) and total absence of beta-EP circadian rhythm were observed in all obese patients. Mean 24 h MEL concentrations were markedly higher (mainly due to increased daytime levels) in all obese patients while the disturbances of MEL secretion in the form of acrophase shift and (or) suppression of its rhythmicity were observed especially in obese women with android phenotype. Circadian beta-EP levels correlated positively with BMI and WHR values and negatively with circadian MEL concentrations. In contrast, no significant correlation was found between the values of BMI, WHR and MEL levels. Our data indicate that alterations of beta-EP secretion occurring in obese women could play a role in inducing disturbances of MEL secretory pattern.

Assessment of relationship between hypothalamo-pituitary dysfunction and peripheral endocrine function in normotensive and hypertensive obese men.

The relationship between hypothalamo-pituitary function and various hormonal factors (insulin, cortisol, thyroid hormones, sex steroid hormones, SHBG, IGF-I) was investigated in 34 obese men (16 normotensive and 18 hypertensive) and 15 healthy male volunteers aged 35 to 50 years. Hyperinsulinaemia in obese men was associated with altered hypothalamo-pituitary function as indicated by impaired GH, PRL and cortisol secretion in response to insulin induced hypoglycaemia. On the other hand, hyperinsulinaemia and disorders in GH, PRL and cortisol release were associated with lower levels of reverse triiodothyronine, gonadotropins, testosterone, 17-corticoids and SHBG and higher levels of triiodothyronine, estradiol, 17-hydroxycorticoids and IGF-I. Various disorders of hypothalamo-pituitary axis and adrenal, thyroid and testicular function occur more frequently in hypertensive obese men with android distribution of adipose tissue.

Association of body mass and body fat distribution with serum melatonin levels in obese women either non-operated or after jejunoileostomy.

The association of body mass index (BMI) and body fat distribution (as measured by waist-to-hip circumference ratio; WHR) with serum melatonin (MEL) levels determined at 02 and 14 h were examined in 22 non-operated obese women and 21 obese women who underwent jejunoileostomy for morbid obesity 2 to 6 years earlier as well as in 20 gender and age-matched healthy controls with normal body weight. All non-operated obese women either with moderate or morbid obesity had significantly higher MEL concentration at 14 h compared with controls, whereas the amount of MEL secreted at 02 h was elevated only in morbidly obese women. The mean differences between serum MEL levels at 14 h and 02 h (delta MEL) was reduced in morbidly obese women - it may be due to desynchronisation of its circadian rhythmicity. Among women who underwent jejunoileostomy for morbid obesity the values of MEL were normalized only in those with a noted body mass reduction and with BMI and WHR indexes less than 28 kg/m² and 0.83, respectively. MEL correlated positively with BMI and WHR indexes at 14 h in all subjects studied. Negative correlation was noted between the relative values of delta MEL and BMI in both non-operated and operated obese women with BMI indexes >31 kg/m².

Effect operative weight reduction on Hypothalamo-Pituitary, -adrenal and -ovarian axes function in obese women with menstrual disturbances.

The aim of the study was to evaluate insulin (Ins), pituitary hormones (GH, PRL, LH, FSH), sex hormone-binding globulin (SHBG) and insulin-like growth factor-I (IGF-I) under basal conditions as well as the changes in GH, PRL and F levels after insulin-induced hypoglycemia in 21 obese women before and one year after jejunoileostomy as well as in 20 healthy female volunteers with normal body weight (aged 27 to 36 years). Before surgery all obese women had irregular menstrual cycles. In 14/21 non-operated morbidly obese women and after operative weight reduction (jejunoileostomy), the GH, PRL and F response to insulin-induced hypoglycemia was lower than that in non-obese healthy controls. No difference, however, was observed in GH, PRL and F secretion in non-operated obese women as compared with obese women after jejunoileostomy. Hypothalamic disturbances in the release of GH, PRL and F corresponded to higher levels of sex steroid hormones, IGF-I, and also to lower values of LH/FSH index and SHBG capacity in serum. After jejunoileostomy the pituitary-ovarian axis function as well as SHBG and IGF-I concentrations were normalized only in patients with a noted body mass reduction and with normal preoperative GH, PRL and F secretion dynamics. In these women the menstruation became regular.

[Rare foreign body in the lumen of the small intestine]. / Niezwykle rzadkie cialo obce w swietle jelita cienkiego.

The pathologic conditions caused by forgotten surgical gauze give rise to many different clinical pictures and are very hazardous for the patient. Such patient are seldom reported in the medical literature, mainly due to legal implications. That's why authors describe a case of surgical gauze forgotten after gynecologist procedure. The interval between the causative operation and the admission in our hospital was 7 months. The tentative diagnosis was jejunal tumor. Definitive diagnosis was made intraoperatively, we find surgical gauze 25 cm x 30 cm of diameter in jejunum with jejuno-jejunal fistula which protect patient against ileus.

[About the matter of injury to the superior laryngeal nerve during strumectomy]. / W sprawie uszkodzenia nerwu krtaniowego górnego podczas strumektomii.

The attention is paid to the frequently overlooked in clinical practice problem of diagnosis and strumectomy, in the light of literature data on peripheral nerve regeneration. The authors point to important causes of frequent failures in the treatment of such complications. They conclude that at the present level of knowledge, the only practical way to avoid the aforementioned complication is the change of surgical technique in routine strumectomy.

[Restoration of alimentary tract continuity due to of fever of unknown origin after surgical treatment of extreme obesity with partial intestinal bypass]. / Odtworzenie ciaglosci przewodu pokarmaowego z powodu goraczki o nieustalonej etiologii po chirurgicznym leczeniu skrajnej otylosci metoda czesciowego wylaczenia jelitowego.

A case is presented of a female patient in whom after the operation of partial small intestinal bypass 45 + 15 + PV for extreme obesity, extreme emaciation developed caused by episodes of hectic fever of not completely explained aetiology, refractory to conservative treatment. Complete permanent regression of symptoms and signs was achieved after restoration of physiological continuity of the alimentary tract.