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Il follow-up postoperatorio in pazienti portatori di bendaggio gastrico e la riabilitazionwe chirurgica
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Pulmonary aspiration in adjustable gastric banding carriers undergoing a second surgical procedure : considerations on personal experience and review of the literature
No full textINTRODUZIONE: La chirurgia bariatrica coinvolge un gran numero di persone annualmente. Il bendaggio gastrico regolabile laparoscopico tuttora rappresenta una considerevole porzione della chirurgia per obesità, anche se la sua frequenza è andata gradualmente diminuendo. Dalle stime della ASMBS, tra il 2011 e il 2015 negli USA sono stati eseguiti più di 145.000 nuovi bendaggi gastrici.
Questa procedura è generalmente eseguita su persone giovani che durante il corso della loro vita potrebbero essere esposte a successivi interventi chirurgici, correlati o meno alla chirurgia bariatrica o alla perdita di peso.
La polmonite da aspirazione è una rara, ma potenzialmente grave complicanza delle operazioni chirurgiche. In letteratura la sua incidenza varia tra 1 / 1116 e 1 / 8761 casi chirurgici (Tabella I). Il presente lavoro riporta una valutazione dell’incidenza della inalazione polmonare nella nostra serie di portatori di bendaggio gastrico sottoposti ad una nuova operazione in anestesia generale.
MATERIALI E METODI: Nel gennaio 2013 dopo aver osservato un episodio di inalazione polmonare durante l’induzione di anestesia generale in un paziente portatore di bendaggio gastrico candidato ad una procedura di rimodellamento corporeo, revisionammo la nostra casisticacasistica per rilevare l’incidenza dell’aspirazione polmonare all’induzione dell’anestesia in pazienti portatori di bendaggio gastrico, sottoposti ad un nuovo chirurgico in anestesia generale. Ritenendo il risultato troppo elevato se comparato alla popolazione generale, decidemmo di sgonfiare il bendaggio gastrico prima di ogni procedura da effettuarsi in anestesia generale. Abbiamo ora rivisto la casistica raccolta fino a dicembre 2016, ed abbiamo paragonato i risultati prima e dopo il cambiamento del protocollo. I due gruppi sono stati comparati mediante il test del chi quadro considerando la p significativa se minore di 0.05.
RISULTATI: Nel nostro centro da gennaio 2004 a dicembre2013 sono stati eseguiti 706 bendaggi gastrici laparoscopica ed altri 143 da febbraio 2013 a dicembre 2016. Tutti questi pazienti sono regolarmente seguiti annualmente, per periodiche regolazioni del bendaggio. Tra questi pazienti, 253 sono stati sottoposti per svariati motivi ad un successivo intervento chirurgico in anestesia generale (Tabella II).
Tra i 172 portatori di bendaggio gastrico sottoposti a nuovo intervento prima di gennaio 2013 abbiamo osservato 3 casi di inalazione polmonare alla induzione dell’anestesia (1/57 - 1.7%).(Tabella III) Dal febbraio 2013 al dicembre 2016, dopo aver deciso di sgonfiare il bendaggio in tutti i portatori di bendaggio candidati per una nuova operazione in anestesia generale, 81 pazienti sono stati sotto posti nuovo intervento. Nessun nuovo caso di aspirazione polmonare è stato osservato (0/81).
DISCUSSIONE:Un enorme numero di pazienti viene sottoposto annualmente a impianto laparoscopico di bendaggio gastrico regolabile per obesità. Si tratta in genere di pazienti giovani, che potrebbero nel corso della loro vita andare incontro ad ulteriori interventi chirurgici correlati alla perdita di peso (chirurgia di rimodellamento corporeo, correzioni di laparoceli, rimozione del bendaggio etc.), o per le cause di intervento che ricorrono nella popolazione comune. A nostra conoscenza non esistono dati sull’incidenza di aspirazione polmonare all’induzione dell’anestesia in questo gruppo di popolazione. La sindrome da aspirazione polmonare è una ben conosciuta e potenzialmente fatale complicanza che ricorre con incidenze variabili tra 1/3216 e 1/8761 operazioni chirurgiche (Tabella III).
Il tasso da noi osservato prima del gennaio 2013 tra i portatori di bendaggio gastrico è stato più elevato che nella popolazione normale. Dopo aver deciso di sgonfiare il bendaggio nei candidati ad una nuova operazione in anestesia generale, pur considerando che la casistica è ancora limitata, non abbiamo più osservato alcun caso. Il test del Chi quadro fra i due gruppi di pazienti prima e dopo l’introduzione del protocollo di sgonfiaggio del bendaggio, è risultato 1.43 con un valore P= 0.23 tuttavia in queste condizioni il test statistico perde di significato. La potenziale gravità della complicanza giustifica ampie misure preventive e, del resto, la deflazione del bendaggio è manovra rapida, poco invasiva e reversibile. CONCLUSIONI: Pur considerando la necessità di più ampie casistiche, riteniamo di raccomandare la deflazione del bendaggio prima di ogni procedura in anestesia generale.
Crediamo che la consapevolezza del rischio di un’aspirazione polmonare in portatori di bendaggio gastrico, sia importante non solo per gli specialisti di chirurgia bariatrica, ma soprattutto per gli anestesisti e i chirurghi generali che si trovino a dover eseguire procedure chirurgiche in anestesia generale in questi pazienti.Ann Ital Chir. 2017 Nov 7;6. pii: S0003469X17027622. [Epub ahead of print]
The observation of a relatively high number of pulmonary aspirations (PA) among gastric band (GB) carriers undergoing a second surgery, prompted us to modify our strategy for GB patients candidate to further operation under general anesthesia.
MATERIAL OF STUDY AND RESULTS:
In January 2013, following the occurrence of PA at the induction of general anesthesia in 1 GB carrier undergoing a further operation, we reviewed our Data Base between January 2005 and 2013, to explore the rate of pulmonary aspiration in patients GB carriers undergoing a second surgery. Considering the rate (3/172 - 1.7%) too high in comparison with non-GB carriers, we decided to deflate the banding before any further surgery planned under general anesthesia. We then retrospectively reviewed the occurrence of PA after having changed the protocol. Since February 2013, through December 2016, 81 GB carriers underwent a second surgery and not a single episode of PA occurred (0/81).
DISCUSSION:
The occurrence of PA in patients with GB seems greater than in non-GB patients. Larger series should be examined to assess the incidence of PA among this specific population. Awareness of the increased risk is important to general anesthesiologists and surgeons, considering the increasing number of GB carriers who may be in need of surgery. Our result after adopting the deflation policy, even though not statistically significant, seems highly suggestive.
CONCLUSION:
We believe that, considering the potentially severe consequences of PA, the gastric band should be deflated before any planned procedure requiring general anesthesia. Further data are needed
The surgical treatment of abdominal wall hernias in day surgery: 5 years of experience
No full textINTRODUCTION: In our department of General Surgery and Oncological Surgery, a unit of ambulatory surgery was instituted in
January 1994, with the aim of reducing the waiting list and healthcare
costs.
METHODS: From January 1994 to October 1998, we operated in day-surgery 681 patients (536 males, mean age 56.3 and 145 females, mean age 48.8): 352 had indirect inguinal, 132 direct inguinal,
41 scrotal, 75 recurrent, 38 femoral, 32 umbilical and 12 epigastric hernias. At the day of the operation, a short term antibiotic prophylaxis 30 minutes before the operation was applied. One
hundred and forty-four patients (21.6%) were submitted to epidural, 529 pts (77.7%) to local and 8 pts (1.2%) to general anesthesia. We used a modified Lichtenstein procedure which consisted
of suturing the polypropylene mesh to Cooper’s ligament in
treatment of the inguinal hernia. We put moreover a polypropylene
plug into the internal inguinal ring, when dilated more than 2 cm,
and always in recurrent hernias. A duplication of the transverse
abdominal aponeurosis was done in all direct hernias, with apposition of a patch and occasionally a plug. In femoral hernias we put a plug in femoral approach and plug mesh in the inguinal approach.
In umbilical and epigastric hernias we set the mesh beneath
the fascia. Visits at 3, 7 days, 3 months and 1 year after operation.
RESULTS: Eight patients were converted to general anesthesia, due to local anesthesia intolerance. At 58th month follow up, we report 93.9% success rate. Post-operative complications rate were 6.0%: 4 seromas, 13 wound hematomas, 15 cases of neuritic pain
and 2 orchitis, which healed after medical treatment. We observed
moreover 5 recurrent inguinal hernias (due to mesh dislocation)
and 2 homolateral femoral hernias, occurring 6 months after the
operation. It was the first year of our experience when we also used the Trabucco procedure. Since then we have always used modified Lichtenstein procedure, applying a single stitch to connect the mesh to the Cooper’s ligament.
CONCLUSION: Our results are excellent with index of satisfaction
very good (98.8%). Further this technique reduces the phycological
stress with less post-operative discomfort and allows an early return
to daily occupation
Injection Port and Connecting Tube Complications after Laparoscopic Adjustable Gastric Banding
No full textBackground: Port-site and connecting tube complications are usually considered minor problems in the follow-up of obese patients submitted to laparoscopic adjustable gastric banding (LAGB), but the incidence reported in literature ranges from 4.3% to 24%. These complications are mainly because of the mechanical stress of the port and the tube; therefore, their incidence might be time dependent and probably increase during the follow-up.
Methods: We evaluated retrospectively 489 obese patients submitted to LAGB from February 1998 to December 2005, considering all the complications of the connecting tube and port. Their clinical signs, imaging exams, operative reports, and hospitalization files were evaluated.
Results: The meam follow-up of the patients was 41 months. Seventy-one patients (14.5%) presented port and connecting tube complications that required 82 revisional operations. Fifty-four patients had system leaks, 3 had infection problems, and 14 mechanical problems, always requiring surgical revision. In five patients, the system leak was observed twice and required a second surgical repair, while one patient presented three times a leakage of the connecting tube and needed three surgical revisions. All cases of system leakage were to significant weight regain. In one case of recurrent port infection, we had to remove the band.
Conclusion: Port-site and connecting tube problems are the most common complications after LAGB. Although they are considered marginal complications, they usually cause weight regain; their correction often requires surgical revision and sometimes removal of the band
Preoperative changes of forced vital capacity due to body position do not correlate with postoperative respiratory function in obese subjects
No full textBackground: Obese patients are at risk of developing postoperative pulmonary complications. We hypothesized that preoperative changes in dynamic spirometry due to body posture would correlate with the drop of forced vital capacity (FVC) measured early after surgery. Methods: 30 consecutive morbidly obese patients undergoing gastric banding were investigated. All subjects were studied the day before surgery (T0) and on postoperative day one (T1). Forced Vital Capacity (FVC) was measured, together with heart rate, mean arterial pressure and respiratory rate. At T0 measurements were taken in a random fashion with subjects in upright and in supine position. Subjects were then investigated after surgery in the supine position (T1). Postoperative pain was assessed at T1 using visual analogue scale. Intraoperative variables were also collected. Results: Body Mass Index (BMI) of the investigated subjects was 43.9 ± 5.7 Kg/m2 (range 33.8 - 60); their age was 40 ± 8 years. All dynamic spirometric data decreased significantly from upright to supine position (P < 0.05) and after surgery from 3.07 L (2.77 - 3.71) to 1.50 (1.15 - 2.12) (FVC T0 supine vs. T1, P < 0.05). Changes of FVC due to body position did not correlate with changes of FVC occurring after surgery (R2 = 0.105, P = 0.081). When subjects were stratified by the median postoperative drop of FVC (45.74%), preoperative (anthropometric and spirometric data), intraoperative (ventilatory settings and hemodynamics) and postoperative (FVC and pain) parameters were similar between groups. The duration of pneumoperitoneum was correlated with the drop of FVC (R2 = 0.551, P < 0.05). Conclusions: The derangement of FVC that occurs in obese subjects after gastric banding is not predictable before surgery from anthropometric or spirometric data. The duration of pneumoperitoneum significantly contributes to postoperative impairment of respiratory functio
The bilio-intestinal bypass
No full textBackground: Since 1990, we adopted the bilio-intestinal bypass (BIBP) for all morbidly obese patients eligible for a malabsorption procedure. Since 2001 we used laparoscopic technique.
Methods: 148 patients, mean age 35.4 (18-63) years; preoper- ative mean weight kg 148.3 (104-225); mean preoperative BMI 54.1 kg/m2 (40-66.2); mean follow-up 10 years (1-22). 83 patients underwent open and 65 laparoscopic BIBP. Laparoscopic BIBP was performed with five lap ports. Section of the jejunum 30 cm distal to the ligament of Treitz and of mesentery was made by a linear stapler. The cholecysto-jejunal anastomosis was completed with 45-mm linear stapler. A side-to-side anastomosis between
the proximal jejunum and the last 12-18 cm of the ileum was cre- ated by firing a 60-mm linear stapler. On the excluded ileum, an anti-reflux valve system was hand-sutured.
Results: 5 years postoperatively, mean weight was 89 (62-130) kg, mean BMI was 31 kg/m2 (24-41). Two patients of the 65 laparoscopic patients were converted to open surgery for adhe- sions post-appendectomy. The main late complications were inci- sional hernia (19.3%) and abdominal bloating (2.9%). The rever- sal and conversion rate was 6.5%. There was no death.
Conclusions: Our experience showed that 5 years post-BIBP, the weight loss was satisfactory in 90.7% of patients. Using laparoscopic technique, it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convales- cence and incisional hernia
Open and laparoscopic approach of the new surgical technique, whitch enables traditional diagnostic evaluation of the bypassed stomach : the roux-en-y gastric bypass on vertical banded gastroplasty
No full textRoutine surgical videothoracoscopy as the first step of the planned resection for lung cancer
Full text linkObjectivesNotwithstanding preoperative staging, a number of procedures still end in an exploratory thoracotomy as a result of unexpected findings. The aim of this work is to evaluate the validity of routine videothoracoscopy, performed as the first step of every planned resection for non–small cell lung cancer, to assess tumor resectability and feasibility of the resection through thoracoscopy.Methods and ResultsFrom November 1991 to December 2007, in our department, 1306 patients with non–small cell lung cancer, judged operable at conventional staging, underwent videothoracoscopy before the operation. Thoracoscopy revealed inoperability in 58 (4.4%) patients, mostly owing to pleural dissemination (2.5%) or mediastinal infiltration (1.7%). In the remaining 1248 (95.6%), thoracoscopy did not reveal inoperability. Of these, 449 (34.4%) underwent thoracoscopic resection. The other 799 (61.2%) underwent thoracotomy: 767 underwent resection, but 32 (2.5%) had an exploratory thoracotomy. Thoracoscopy had suggested unresectability in 7 (0.5%) patients, had been incompletely carried out in 4 (0.3%), and was unfeasible in 21 (1.6%) owing to insurmountable technical reasons. In our previous series from 1980 to 1991 the exploratory thoracotomy rate had been 11.6%. In the present series, after the introduction of routine thoracoscopy in the staging process, the exploratory thoracotomy rate was 2.5%. Thoracoscopy was reliable in excluding unresectability (negative predictive value 0.97). The global percentage of correct staging was significantly better (P < .0001) by thoracoscopy (73.3%) than by computed tomography (48.7%). Considering T descriptor, video-assisted thoracic surgery correctly matched with final pathologic staging in 96.2% of patients.ConclusionsRoutine preliminary videothoracoscopy ensured assessment of tumor resectability and feasibility of the resection through thoracoscopy and limited unnecessary thoracotomies
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