Gallstone formation and subsequent cholecystectomy after oncological gastric and esophageal resection.

PURPOSE: Gallstone formation is increased after gastric (GR) or esophageal resection (ER); however, the exact pathophysiology is not fully understood yet. Symptomatic cholecystolithiasis and the need for subsequent cholecystectomy after upper gastrointestinal resection can alter the outcome in oncological patients. There is an ongoing discussion if these patients benefit from a simultaneous prophylactic cholecystectomy. This study aims to analyze the risk of gallstone formation after GR or ER and the perioperative course of a subsequent cholecystectomy. METHODS: In this study, all patients were included, who underwent an oncological gastric or esophageal resection at the Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery in the years 2003-2021. RESULTS: A simultaneous cholecystectomy was performed in 29.8% with GR and in 2.1% with ER (p < 0.001). There was no significant difference in complications or length-of-stay between patients with simultaneous vs. no simultaneous cholecystectomy. Newly developed gallstones tended to be more common after GR (16% vs. 10% ER), after reconstruction without preservation of the duodenal passage (17% vs. 11% with) and after GR with lymph node dissection (19% vs. 5% without). After ER, subsequent cholecystectomy was significant less frequently (11.4% vs. 2.9% OR) (p = 0.005). The subsequent cholecystectomy was performed openly in 57.1% with major complications classified as Clavien-Dindo ≥ 3a in 14.3%. CONCLUSION: Based on the findings of our study, we do not recommend simultaneous cholecystectomy routinely in oncological gastric or esophageal resections. An individualized approach depending on risk factors like extensive lymphadenectomy or duodenal passage can be discussed.

Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years.

INTRODUCTION: Having performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication. OBJECTIVES: We report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation. RESULTS: The operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery. CONCLUSION: Both the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

Bariatric surgery prevents carotid wall thickness progression.

BACKGROUND: Bariatric surgery is a treatment option for patients with severe obesity and improves parameters of cardiovascular and/or metabolic disease. Carotid intima media thickness (C-IMT) is a surrogate measure of subclinical atherosclerosis. Previous studies showed short to mid-term arrest and even regression of C­IMT progression following bariatric surgery. We aimed to investigate the long-term effect of weight loss on C­IMT progression 10 years after bariatric surgery in comparison to a population-based control cohort. METHODS: In total, 21 eligible patients were examined preoperatively, at 5 and 10 years after bariatric surgery. Anthropometric parameters, plasma triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), insulin, and glucose were assessed at all three study visits. C­IMT was measured via B­mode scans of the common carotid artery. C­IMT progression was measured in an age-matched and BMI-matched cohort selected from the population-based Bruneck study to compare with changes in C­IMT progression after bariatric surgery. RESULTS: C­IMT remained stable over the 10-year observation period after bariatric surgery. The control cohort showed a significant C­IMT progression over 10 years. The difference in C­IMT progression over 10 years was significant (p < 0.01) between both cohorts. CONCLUSION: Weight loss induced by bariatric surgery halts the natural progression of C­IMT over a 10-year observation period.

Linear or circular: Anastomotic ulcer after gastric bypass surgery.

BACKGROUND: After laparoscopic Gastric Bypass Procedure (GBP), anastomotic ulcers (AU) at the gastrojejunostomy (GJ) occur in up to 16% of the patients. Surgical techniques seem to influence the development of AU, but this is still a matter of discussion. This study aims to compare the incidence of AU in circular-stapled (CS) versus linear-stapled (LS) gastrojejunostomy. METHODS: Single-centre retrospective analysis of 241 (m 77 /f 164) consecutive patients (126 CS, 115 LS) with primary or revisional GBP including Roux-Y-Gastric Bypass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) between 01/2014 and 01/2018. Follow-up with oesophagogastroduodenoscopy was only performed in symptomatic patients. Age, body mass index (BMI), comorbidities, smoking and medication were analyzed in both groups. The data are reported as total numbers (%) and mean ± standard deviation. RESULTS: AU occurred significantly more often in the CS group than in the LS group (p = 0.0034). Moreover, refractory AU and the need for revisional surgery were higher in the CS group. Smoking correlates significantly with the development of AU, whereas other risk factors had no impact on its incidence. CONCLUSION: Linear-stapled gastrojejunostomy with a long and narrow pouch should be the preferable procedure for reducing AU development risk. Smoking cessation minimizes the risk for AU and is a necessary part of the treatment.

[Planning and Design of a Prospective Randomised Multi-Centre Trial on the Repair of Large Hiatal Hernias with Sutures vs. Pledgeted Sutures vs. Absorbable Mesh]. / Vorstellung einer prospektiv randomisierten Multicenterstudie zum Vergleich der Hiatusplastik mit Nähten vs. Nähte mit Pledgets vs. resorbierbares Netz bei großen Hiatushernien.

BACKGROUND: The hernia recurrence rate after surgical treatment of large hiatal hernias is still very high. The optimal technique to reduce the recurrence rate is still under debate. The aim of this work is to clarify whether pledgeted reinforced sutures or a resorbable mesh can reduce the recurrence rate compared to hiatus closure with only sutures. MATERIALS AND METHODS: An Austria-wide, multi-centre, prospective, randomised study was planned. The study protocol was prepared by the main test centre (University Clinic for General, Visceral and Thoracic Surgery, Paracelsus Medical University Salzburg). The study includes patients who are scheduled to undergo laparoscopic or robot-assisted surgery for a large symptomatic hiatal hernia. A large hiatal hernia is defined as > 5 cm in manometry or gastroscopy or at least ⅓ of the stomach lying intrathoracically. The primary study endpoint is defined as the hernia recurrence rate, objectively assessed by gastroscopy. After inclusion in the study, patients will be followed up for 6 months, 1 year, 3 years and 5 years after the operation, using standardised questionnaires and gastroscopy. The power calculation showed a requirement of 55 patients per group. Preoperative randomisation and data management are software-based. RESULTS: The study approval by the leading ethics committee is currently pending and the study itself has been registered on ClinicalTrials.gov since October 2020. The Clinical Trials Registration Number is NCT04591860. Five clinics are participating in the study at the moment and all centres are actively enrolling patients. The duration of the study is set until January 2027. CONCLUSION: This study is the world's first prospective randomised study that examines the value of pledgets and resorbable mesh to reduce the recurrence rate after treatment of large hiatal hernias. The results will help to find the optimal technique to close the hiatus of large hiatal hernias.

Laparoscopic Adjustable Gastric Banding: an Underestimated Risk Factor for the Development of Esophageal Cancer?-a Nationwide Survey.

BACKGROUND: Approximately 14% of Austria's 8.5 million inhabitants have a body mass index (BMI) > 30 kg/m2. The laparoscopic adjustable gastric banding (LAGB) was introduced in Austria in 1994, where about 10.300 patients have received it so far. One of our LAGB patients developed an adenocarcinoma of the distal esophagus 13 years after implantation. OBJECTIVES: In order to calculate whether after LAGB patients are at higher risk for carcinoma of the esophagus, we performed a nationwide survey. METHODS: A questionnaire was sent to all surgical departments in Austria, primarily in order to detect cases with esophageal carcinoma after LAGB, but also to evaluate the policy in Austria concerning preoperative work-up, operation, and follow-up in LAGB patients. RESULTS: Since 1994, 37 of the 119 surgical departments in Austria have performed a total of about 10.300 LAGB implantations. Six patients have been identified with esophageal cancer following LAGB. The WHO statistical report on esophageal cancer shows an incidence of 2.8/100.000 per year in Austria, about 1/3 of which cases are adenocarcinoma of the distal esophagus. CONCLUSION: Following LAGB, the incidence of esophageal cancer might be up to fivefold higher than the aged standardized overall population of Austria.

Laparoscopic sleeve gastrectomy: gateway to kidney transplantation.

BACKGROUND: The prevalence of obesity and obesity-related morbidity in end-stage renal disease patients is rising. Although it is established that obesity does not abrogate the transplant benefit with respect to lower long-term mortality and cardiovascular risk, it is associated with increased graft failure, delayed graft function, surgical complications, prolonged hospital stay, and costs. OBJECTIVES: To examine the safety and efficacy of LSG (laparoscopic sleeve gastrectomy) in renal transplant candidates and evaluate transplant outcomes. SETTING: Single-center prospective nonrandomized trial METHODS: We here report on a prospective single-center trial establishing a 2-step approach for obese renal transplant candidates. Patients with end-stage renal disease and a BMI (body mass index) of 35 kg/m2 or higher underwent laparoscopic sleeve gastrectomy. After reaching a BMI of<35 kg/m2, patients were waitlisted for kidney transplantation. Age, gender, body mass index (BMI), associated co-morbidities, cause of end-stage renal disease, surgical complications, and outcome after kidney transplantation (graft survival, incidence of delayed graft function, incidence of rejection, serum creatinine) were collected. RESULTS: LSG was performed in 8 renal transplant candidates with a mean BMI of 38.8 kg/m2 each. BMI dropped to below 35 kg/m2 within a median of 3 months. Percent excess body mass index loss (%EBMIL) was 62.7% at 1 year after LSG. Within 17 months (mean) after metabolic surgery, 7 patients underwent kidney transplantation. All transplants were successful with a serum creatinine of 1.9±.8 mg/dL at discharge and stable allograft function thereafter. Mean follow-up was 3.2±1.4 years; no patient was lost to follow-up. CONCLUSION: LSG is safe and efficacious for treatment of obesity in renal transplant candidates. Rapid and sustained weight loss and subsequent waitlisting for kidney transplantation may reduce overall and in particular posttransplant patient morbidity.

Significant pressure differences between solid-state and water-perfused systems in lower esophageal sphincter measurement.

OBJECTIVE: High-resolution manometry of the esophagus has gained worldwide acceptance, using different solid-state catheters. Thus, normal values for lower esophageal sphincter (LES) resting pressure in suspected gastroesophageal reflux disease patients have been established using water-perfused manometry. These standard values are commonly applied using also solid-state techniques, although they have never been compared before. The aim of the study was to compare LES measurements obtained with water-perfused manometry with a solid-state technique. METHODS: Thirty healthy subjects were studied twice on the same day: Technique 1: Station pull through using a water-perfused catheter with ports arranged at 0°, 90°, 180° and 270° which were averaged to give a mean LES pressure. Technique 2: Solid-state circumferential probe with a single station pull through. Data were collected using the same computer system and program. The LES pressures were randomly and blindly analyzed. RESULTS: Twenty-seven subjects out of 30 were analyzed. Using the solid-state system, the mean LES pressure was higher (15.0 vs. 23.3 mmHg, p = 0.003) and 19 of 27 (70%) individual measurements were higher. Two subjects had a hypertensive LES by solid state (58.6 resp. 47.5 mmHg), while their pressures were normal with water-perfused manometry (21.0 resp. 23.4 mmHg). The distal esophageal pressures (mean of pressure at 3 and 8 cm above LES) were the same with the two techniques. CONCLUSION: In normal control subjects, LES measurement using circumferential solid-state transducers yields higher pressures than standard water-perfused manometry. Which system yields the "true" resting pressure of the physiologic LES remains to be determined.

Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary.

BACKGROUND: Laparoscopic sleeve gastrectomy has gained popularity among bariatric surgeons. The purpose of this study was to evaluate the usefulness of early upper gastrointestinal (UGI) contrast studies in the detection of postoperative complications. METHODS: Radiographic reports were reviewed from April 2006 to January 2013. During that time, 161 patients underwent laparoscopic sleeve gastrectomy. All patients were submitted to UGI examination on postoperative day (POD) 1. RESULTS: Among the 161 patients who underwent UGI, no contrast leaks were found on POD 1. Three patients (1.9%) developed stapler line leaks near the gastroesophageal junction, which were diagnosed on PODs 3, 4, and 10. Gastroesophageal reflux in 5 patients (3.1%) and delayed gastroesophageal transit in 10 patients (6.2%) were detected. CONCLUSIONS: The results of this study show that UGI series on POD 1 cannot assess the integrity of the gastric remnant. Early UGI series are not required as routine procedures in all operated patients. Computed tomographic swallow studies should be performed in patients who postoperatively develop clinical signs and symptoms of complications such as tachycardia, pain, or fever.

Aorto-Esophageal Fistula After Thoracic Endovascular Aortic Repair: Successful Open Treatment.

We present the case of a 56-year-old patient suffering from an aorto-esophageal fistula after complex treatment of acute Type A dissection including thoracic endovascular aortic repair (TEVAR) of the descending aorta. Open surgical descending replacement using a pericardial patch, as well as esophagectomy, was performed. After a long and complicated hospital stay, the patient finally recovered and was discharged in stable condition. By choosing an aggressive surgical approach the patient survived this devastating complication of TEVAR, which is associated with high mortality.

Initial experience with robotic lung lobectomy: report of two different approaches.

BACKGROUND: Surgical resection is the gold standard for treatment of early-stage lung tumors. Different minimally invasive approaches are currently under investigation: In addition to conventional video-assisted thoracoscopic surgery (VATS), robotic technology with the da Vinci System has emerged over the past 10 years. METHODS: In this series, 26 patients (12 women and 14 men; median age, 65 years) underwent a robotic lobectomy for early-stage lung tumors (clinical stage IA or IB) or centrally located metastases. RESULTS: The resected lobes included four left upper lobes, six left lower lobes, eight right upper lobes, and eight right lower lobes. Five intraoperative conversions to open thoracotomy were performed due to one major bleeding, two minor bleedings, one variant course of the pulmonary artery, and one extended resection. The postoperative complications included two prolonged air leaks, one colonic perforation, and one atrial fibrillation. The median hospital stay was 11 days (range, 7-53 days). One 30-day mortality (3.8%) occurred due to respiratory failure. The overall median operative time was 228 min (range, 162-375 min). For the first five patients, the posterior approach was used. Thereafter, the authors switched to an anterior approach, thus enabling an easier hilar dissection. Technical modification within this series also included the introduction of a new vessel sealing device. CONCLUSION: Robotic lobectomy was proved to be feasible and safe in our initial series in a learning curve setting. Changes in patient positioning and approach as well as technical modifications resulted in shorter operative times. A longer follow-up period and randomized controlled trials are necessary to evaluate a potential benefit over open and conventional VATS approaches.

Robot-assisted laparoscopic cardiomyotomy.

INTRODUCTION: Robot-assisted laparoscopic surgery is an expanding field of medicine. In endoscopic microsurgery particularly, difficult maneuvers such as intracorporeal hand-sewn anastomoses or a narrow operating field are ideal indications for use of an operation robot. PATIENTS AND METHODS: Six patients, four men and two women, underwent robot-assisted laparoscopic cardiomyotomy for achalasia at a tertiary referral center with substantial expertise in robotic surgery. A detailed description of the operation technique is provided, together with a review of the literature. RESULTS: Robot-assisted laparoscopic cardiomyotomy was feasible without any particular problem and the postoperative course of all six patients was uneventful. The operation time was 236 (220-316) minutes, plus 38 (25-47) minutes for setup-time of the robot. At follow-up six months postoperatively, five of the six patients were free of significant dysphagia and all were free of reflux symptoms. DISCUSSION: There are several published reports, series and trials on robot-assisted laparoscopic cardiomyotomy. The general conclusion is that in experienced hands this operation is easy to perform, with a significantly lower rate of mucosal perforations, but that overall costs are higher, including a longer operation time during the learning curve. The avoidance of mucosal lacerations and their possible consequences has to be weighed against higher overall costs. CONCLUSION: Laparoscopic cardiomyotomy is the first standard laparoscopic operation where a clear advantage for use of an operation robot has been proven. Thus, wherever an operation robot is available it should be used for this procedure.

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.

Chylous cyst formation following laparoscopic fundoplication.

Formation of an abdominal chylous cyst is a rare event, predominantly occurring after spinal, vascular or urologic retroperitoneal surgery. As far as we know, the presented case is the first report in the literature of chylous cyst formation after laparoscopic fundoplication. A 57-year-old man with a history of a conservatively treated spinal compression fracture (T11/12) underwent laparoscopic fundoplication in 1996 for recurrent heartburn with insufficient response to treatment with PPI. His reflux symptoms disappeared but over the following years he developed intermittent abdominal pain in the right upper quadrant. Gastroscopy in 2002 revealed a slight compression of the distal esophagus. CT scan revealed a cystic formation next to the distal esophagus which was initially interpreted to be part of the fundoplicate itself. Aggravation of symptoms and weight loss was noted in 2006. A further CT scan revealed a 7 cm cyst along the fundoplicate and the lesser curvature of the stomach. The cyst was subsequently drained laparoscopically. Cholesterol (351 mg/d), LDL-cholesterol (263 mg/dl), triglycerides (334 mg/dl) and chylomicrons led to the diagnosis chylous cyst and the patient was put on a medium-chain triglyceride diet. After 12 weeks the discharge stopped and the drain was removed. The patient remained symptom-free for seven months but then presented again with the same complaints. This time an even larger cyst was diagnosed, extending from the lesser curvature of the stomach through the esophageal hiatus up to the right atrium. A Roux-en-Y chylous cystojejunostomy was then performed and has solved the problem up to the present. A chylous cyst may develop after laparoscopic fundoplication. If simple drainage fails, a cystojejunostomy can solve this problem.

Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors.

BACKGROUND: Robotic surgical systems are most effective for operations in areas that are small and difficult to reach. Ideal indications for this new technology have yet to be established. The esophagus possesses attributes that are interesting for general thoracic robotic surgeons. METHODS: Robotic-assisted thoracoscopic surgery (RATS) using the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) was performed in six patients with esophageal tumors. This comprised the dissection of the intrathoracic esophagus including lymph node dissection in four patients suffering from esophageal cancer and the extirpation of a benign lesion (one leiomyoma and one foregut cyst) in the remaining two patients. RESULTS: All procedures were completed successfully with the robot. The median overall operating time was 173 (160-190) minutes in the oncologic cases and 121 minutes in the benign cases, including the robotic act of 147 (135-160) minutes and 94 minutes, respectively. There were no intraoperative complications. One patient had to undergo a redo thoracoscopy because of a persistent lymph fistula. One cancer patient died after 12 months due to tumor progression and another patient had to be stented due to local tumor recurrence 19 months postoperatively. CONCLUSIONS: This first small series of various esophageal pathologies treated by robotic-assisted thoracoscopic surgery supports the impression that the esophagus is an ideal organ for a robotic approach. The potential of the da Vinci system, especially for oncologic indications, remains to be proven in future clinical trials.

Long-term follow-up after robotic cholecystectomy.

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30-35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.

Listeria meningitis in transplant recipients.

INTRODUCTION: Meningitis is a rare complication following organ and stem-cell transplantation and can be caused by a variety of microorganisms. AIM: To retrospectively review the clinical course and outcome of five cases of listeriosis in four organ recipients and one stem-cell recipient during a seven-year period. PATIENTS AND METHODS: Patient records for more than 3500 patients undergoing organ or stem-cell transplantation at the university hospital of Innsbruck during a 27-year period were evaluated. Standard immunosuppression consisted of calcineurin inhibitor-based triple drug therapy with or without ATG or IL2 receptor antagonist induction. RESULTS: The first case affected a 35-year-old woman who received an allogenic bone marrow transplant for advanced breast cancer. Cases two and three related to two male heart recipients. Cases four and five were diagnosed in one male and one female renal recipient. Listeria monocytogenes was isolated from blood in two cases and from cerebrospinal fluid in three. Treatment consisted of ampicillin in all cases with the addition of tobramycin (1), TMPS (1), meropenem (2) or imipenem/cilastatin (1). The deaths of two patients were directly related to L. monocytogenes. CONCLUSIONS: Although listeriosis is a rare complication following transplantation, this infection should be ruled out in individuals presenting with neurological symptoms and fever.