Helmut Weiss

Combined kidney-pancreas transplantation is the treatment of choice for end-stage diabetic nephropathy. Weight gain post-transplant increases the risk for post-transplant complications and death due to cardiovascular events. Gastric pacemakers have been used for therapy of diabetic gastropathy and for the treatment of moderate morbid obesity. We report a patient who experienced significant weight gain following successful kidney-pancreas transplantation and was thereafter successfully treated for diabetic gastroparesis and morbid obesity by use of a laparoscopically implanted gastric pacemaker.

During the last decade obesity has become a health crisis of epidemic dimensions. According to definition, more than 20% of the Western European population and more than 30% of the American population are affected by obesity to some extent.^1,2 Various surgical treatment options have been described, and good results are documented for several laparoscopic restrictive or malabsorptive procedures.^3-6 In Europe, the adjustable gastric band (AGB) has become the preferred method for surgical treatment of morbidly obese patients.⁷

Background: This paper reports the outcome of surgical revision for complications following laparoscopic placement of an adjustable silicone gastric band (AGB) to treat morbid obesity. Methods: Seventy-three (19·1 per cent) of 382 patients who underwent laparoscopic AGB placement between January 1996 and March 2001 presented with complications within 6 years after operation. Revision was carried out with the intention of reinstating the functional device in all patients. Results: Successful surgical revision or gradual balloon deflation was performed in 53 patients (29 port-related complications, 14 pouch dilatations, 12 band leakages, three oesophageal dilatations, two symptomatic hernias, one late migration, one intracerebral bleed). Of these patients, 51 (96·2 per cent) had a successful outcome according to the Bariatric Analysis and Reporting Outcome System following significant additional postinterventional weight loss. AGB removal was carried out in 20 patients (13 early or late migrations, five pouch dilatations, three port-related complications, two psychiatric disorders, one band leakage). The final failure rate for complicated AGB procedures was 30·1 per cent. Conclusion: AGB placement is associated with a variety of complications. In most cases surgical complications can be treated with minimally invasive surgery, which should allow further weight loss and improvement of quality of life during long-term follow-up. Alternative bariatric procedures should be reserved for patients with poor outcome after surgical revision of the AGB.

RADIATION FOR the treatment of carcinoma of the pelvic region has been found to have a significant impact on anal sphincter function.¹ Effects of irradiation on anorectal function are dose dependent. Although the total radiation dose is less in patients with rectal carcinoma than in patients treated for cervical or anal carcinoma, impairment of the anal sphincter has been described.² In addition, operative trauma occurring with low anterior resection of the rectum may lead to further functional disorder. The introduction of nerve-sparing total mesorectal excision (TME) by MacFarlane et al³ resulted in a decreased incidence of complications due to nerval injury, such as urinary incontinence and impotence. However, quality of life after TME may be impaired by disturbed anal continence and fecal urgency. Neoadjuvant chemoradiation in patients with advanced rectal cancer has proven to show oncologic benefit⁴ but may have an impact on the functional entity of the anal sphincter. Recently, Gervaz et al⁵ published a short-term follow-up study of anal sphincter function after chemoradiation for rectal cancer. In their series, resting pressure of the anal sphincter was reduced after chemoradiation within the postoperative observation period of 8 to 12 weeks. As a conclusion, adequate shielding of the anal sphincter was therefore recommended. However, in another study published by Birnbaum et al,⁶ anorectal function was not altered after pelvic irradiation. In these patients, the mean distance of the lower edge of tumors from the dentate line was 7.4 cm. The surgical trauma itself was considered to account for any functional sphincter defects.

Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial. Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively. Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies. Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.

Background: Patients with gastroesophageal reflux disease (GERD) have alterations of gut neuropeptides, such as neurotensin (N) and motilin (M), which are resolved following antireflux surgery....

Background: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. Methods: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. Results: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. Conclusions: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.

Obesity is a prevalent health problem that has discernible impact on all fields of surgery. However, little attention is paid in the literature to the underlying relation of surgical, immunological...