A Rare Cause of Acute Upper Gastrointestinal Hemorrhage

Acute upper gastrointestinal tract hemorrhage represents a frequent morbidity which can be localized and treated endoscopically. When endoscopic treatment alone is failing, radiological or surgical treatment may be warranted. A case history will be presented regarding a rare cause of intestinal hemorrhage with an extraordinary course of illness

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care

Contains fulltext : 155265.pdf (publisher's version ) (Closed access)BACKGROUND: Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC). METHODS: This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates. RESULTS: Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively. CONCLUSIONS: The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources

Long-Term Effects of Laparoscopic Roux-en-Y Gastric Bypass on Diabetes Mellitus, Hypertension and Dyslipidaemia in Morbidly Obese Patients

Contains fulltext : 138553.pdf (publisher's version ) (Closed access)BACKGROUND: Severely obese patients have an increased risk for developing metabolic complications such as type 2 diabetes mellitus (T2DM), dyslipidaemia (DL) and hypertension (HT). The aim of the present study is to research the effect of a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) on T2DM, HT and DL in the long-term. METHODS: Fifty-two out of 89 (58 %) adult severely obese patients with T2DM who had received a LRYGB between January 2000 and December 2008 were evaluated. Primary outcome of evaluation was remission of T2DM according to the definition of 2009 consensus statement. Complete remission was defined as achievement fasting plasma glucose (FPG) of <5.6 mmol/l (<100.8 mg/dL) and HbA1c <42 mmol/mol (<6.0 %)) without glucose-lowering medication for at least 1 year. Partial remission was defined as a FPG of 5.6-6.9 mmol/l (100.8-124.2 mg/dL) and HbA1c 42-48 mmol/mol (6.0-6.5 %), without glucose-lowering medication for at least 1 year. Remission of T2DM was considered if the patient met the criteria for complete or partial remission. Secondary outcomes were remission of HT, DL and changes in medication use. RESULTS: Patients had a mean age of 47.5 +/- 9.6 years, body mass index of 46.6 +/- 6.4 kg/m(2) and a mean duration of T2DM of 6.1 +/- 5.4 years at the time of surgery. The mean post-operative follow-up period was 6.9 +/- 2.3 years. At the end of the follow-up, mean weight loss was 60 +/- 24 % excess weight loss (EWL) and 26 +/- 10 % total body weight loss (TBWL). Mean HbA1c level had significantly decreased from 64.8 +/- 19.7 mmol/mol to 46.4 +/- 12.9 mmol/l (p < 0.0001). Overall medication use was reduced from 85 % to 37 % of the patients (p < 0.0001), while the number of insulin users was reduced from 40 % to 6 % (p < 0.0001). Nineteen percent of the patients had a relapse of T2DM during follow-up. Pre-operative HbA1ac level (odds ratio 0.911, p = 0.020) and duration of T2DM (odds ratio 0.637, p = 0.010) were independent risk factors for failed remission of T2DM. The number of patients with HT was significantly reduced from 73 % to 54 % (p = 0.042), and number of patients with DL was non-significantly decreased from 71 % to 54 % (p = 0.068). CONCLUSIONS: The laparoscopic RYGB operation results in a sustained EWL of 60 % (26 % TBWL) with 52 % long-term remission of T2DM. However, 19 % of the patients had a relapse of their T2DM. Furthermore, HT and DL improved markedly.8 p

Effectiveness and Safety of Sleeve Gastrectomy, Gastric Bypass, and Adjustable Gastric Banding in Morbidly Obese Patients: a Multicenter, Retrospective, Matched Cohort Study

Contains fulltext : 155130.pdf (publisher's version ) (Closed access)BACKGROUND: Laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most performed procedures worldwide (92 %) nowadays. However, comparative clinical trials are scarce in literature. The objective of this study was to compare the effectiveness and safety of the three most performed bariatric procedures. METHODS: A multicenter, retrospective, matched cohort study was conducted. Patients were eligible for analysis when a primary procedure was performed between 2007 and 2010 in one of the two specialized bariatric centers. Primary outcome was weight loss, expressed in the percentage excess weight loss (%EWL). Secondary outcome parameters are hospital stay, complication rate, and revisional surgery. RESULTS: In total, 735 patients, 245 in each group, were included for analysis. The groups were comparable for age and gender after matching. Mean postoperative follow-up was 3.1 +/- 1.2 years. LAGB patients showed less %EWL compared to LSG and LRYGB at all postoperative follow-up visits. LRYGB showed a %EWL of 71 +/- 20 % compared to LSG (76 +/- 23 %; p = 0.008) after 1-year follow-up; thereafter, no significant difference was observed. After 3 years of follow-up, LAGB showed a higher complication rate compared to LSG and LRYGB (p < 0.05). Revisional surgery after LAGB was needed in 21 %, while 9 % of the LSG underwent conversion to RYGB. CONCLUSIONS: LRYGB is a safe and effective treatment in morbid obese patients with good long-term outcomes. LSG seems to be an appropriate alternative as a definitive procedure, in terms of weight reduction and complication rate. LAGB is inferior to both LRYGB and LSG

Prophylactic mesh placement to prevent parastomal hernia, early results of a prospective multicentre randomized trial

PURPOSE: Parastomal hernia (PSH) is a common complication after colostomy formation. Recent studies indicate that mesh implantation during formation of a colostomy might prevent a PSH. To determine if placement of a retromuscular mesh at the colostomy site is a feasible, safe and effective procedure in preventing a parastomal hernia, we performed a multicentre randomized controlled trial in 11 large teaching hospitals and three university centres in The Netherlands. METHODS: Augmentation of the abdominal wall with a retromuscular light-weight polypropylene mesh (Parietene Light, Covidien) around the trephine was compared with traditional colostomy formation. Patients undergoing elective open formation of a permanent end-colostomy were eligible. 150 patients were randomized between 2010 and 2012. Primary endpoint of the PREVENT trial is the incidence of parastomal hernia. Secondary endpoints are morbidity, pain, quality of life, mortality and cost-effectiveness. This article focussed on the early results of the PREVENT trial and, therefore, operation time, postoperative morbidity, pain, and quality of life were measured. Results : Outcomes represent results after 3 months of follow-up. A total of 150 patients were randomized. Mean operation time of the mesh group (N = 72) was significantly longer than in the control group (N = 78) (182.6 vs. 156.8 min; P = 0.018). Four (2.7 %) peristomal infections occurred of which one (1.4 %) in the mesh group. No infection of the mesh occurred. Most of the other infections were infections of the perineal wound, equally distributed over both groups. No statistical differences were discovered in stoma or mesh-related complications, fistula or stricture formation, pain, or quality of life. CONCLUSIONS: During open and elective formation of an end-colostomy, primary placement of a retromuscular light-weight polypropylene mesh for prevention of a parastomal hernia is a safe and feasible procedure. The PREVENT trial is registered at: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2018

Prophylactic Mesh Placement During Formation of an End-colostomy Reduces the Rate of Parastomal Hernia: Short-term Results of the Dutch PREVENT-trial

OBJECTIVE: The aim of this study was to investigate the incidence of parastomal hernias (PSHs) after end-colostomy formation using a polypropylene mesh in a randomized controlled trial versus conventional colostomy formation. BACKGROUND: A PSH is the most frequent complication after stoma formation. Symptoms may range from mild abdominal pain to life-threatening obstruction and strangulation. The treatment of a PSH is notoriously difficult and recurrences up to 20% have been reported despite the use of mesh. This has moved surgical focus toward prevention. METHODS: Augmentation of the abdominal wall with a retro-muscular lightweight polypropylene mesh was compared with the traditional formation of a colostomy. In total, 150 patients (1:1 ratio) were included. The incidence of a PSH, morbidity, mortality, quality of life, and cost-effectiveness was measured after 1 year of follow-up. RESULTS: There was no difference between groups regarding demographics and predisposing factors for PSH. Three out of 67 patients (4.5%) in the mesh group and 16 out of 66 patients (24.2%) in the nonmesh group developed a PSH (P = 0.0011). No statistically significant difference was found in infections, concomitant hernias, SF-36 questionnaire, Von Korff pain score, and cost-effectiveness between both study groups. CONCLUSION: Prophylactic augmentation of the abdominal wall with a retromuscular lightweight polypropylene mesh at the ostomy site significantly reduces the incidence of PSH without a significant difference in morbidity, mortality, quality of life, or cost-effectiveness