Die laparoskopische Antirefluxchirurgie befindet sich in der Anfangsphase und zeigt vielversprechende erste Resultate. Die Antirefluxoperationen sollten bei Patienten mit einer progressiven Form der g
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Laparoscopic gastric banding (LAGB) is the most popular surgical procedure for morbid obesity in Europe. Long-term complications like slippage of the band or pouch dilatation are well known and lead to reoperations in a substantial number... more
Laparoscopic gastric banding (LAGB) is the most popular surgical procedure for morbid obesity in Europe. Long-term complications like slippage of the band or pouch dilatation are well known and lead to reoperations in a substantial number of patients. In this study, results and follow-ups of patients with reoperations after gastric banding were analyzed. Between May 1997 and June 2006, 172 patients were treated with LAGB for morbid obesity. 41 of these patients underwent one or more band-related reoperations (female symbol = 32, male symbol = 9). Causes for and type of reoperation were analyzed. Weight loss and comorbidities were compared for different types of reoperations. There were no deaths following the reoperations. Band replacement (n = 18), band repositioning (n = 7), conversion to sleeve gastrectomy (SG, n = 2) and Roux-en-Y gastric bypass (RYGBP, n = 2) or band removal without any further substitution (n = 12) were performed as first reoperation. Seven patients had a second reoperation: RYGBP (n = 3), SG (n = 1), or band removal (n = 3). Median follow-up since reoperation was 56 months (range 7-113). Excess weight loss (EBWL%) of patients was 59.4% after RYGBP (n = 5), 45.1% after re-banding (n = 18), and 33.4% after SG (n = 2). Comorbidities were further reduced or even resolved after reoperation. Patients whose band was removed without subsequent bariatric procedures lost significantly less weight (n = 13, EBWL% 23.4) than patients with band replacement (n = 18, EBWL% 46.4, p = 0.04). Laparoscopic reoperation after LAGB is safe and feasible. Reoperation leads to further decrease of BMI and obesity-related comorbidities. Band replacement is a good option for patients with good weight loss after initial LAGB. Alternative procedures, preferably RYGBP, are required for cases of band failure. Overall, RYGBP appears to be the most effective option to induce further weight loss.
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Research Interests: Gastroenterology, Forecasting, Adolescent, Multivariate Analysis, Humans, and 15 moreFemale, Male, Lower Esophageal Sphincter, Clinical Sciences, Aged, Middle Aged, Adult, Esophagus, Ambulatory BP monitoring, Gastroesophageal Reflux, Gastroesophageal Reflux Disease, Logistic Models, Esophagoscopy, Gastrointestinal surgery, and Esophagogastric junction
Columnar-lined epithelium with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) is a premalignant condition caused by chronic gastroesophageal reflux disease. Progression of intestinal metaplasia may... more
Columnar-lined epithelium with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) is a premalignant condition caused by chronic gastroesophageal reflux disease. Progression of intestinal metaplasia may be avoided by antireflux surgery, whereas regeneration of esophageal mucosa could be achieved by endoscopic argon plasma coagulation (EAPC). The aim of this prospective study was to show the early results of a combination of EAPC and antireflux surgery. Thirty patients with Barrett's esophagus were treated between August 1996 and December 1999. Regeneration of esophageal mucosa was achieved with several sessions of EAPC under general anesthesia. All patients were receiving a double dose of proton pump inhibitors. Endoscopic follow-up was performed 6 to 8 weeks after the last session. Antireflux surgery (Nissen [n = 26] or Toupet [n = 4] fundoplication) followed complete regeneration of the squamous epithelium in the esophagus. One year after laparoscopic fundoplication and EAPC follow-up with endoscopy and quadrant biopsies of the esophagus, 24-hour pH monitoring and esophageal manometry were performed. All 30 patients showed complete regeneration of the squamous epithelium after a median of two sessions (range 1 to 7) of EAPC. Twenty-two patients underwent 1-year follow-up studies. All showed endoscopically an intact fundic wrap. Recurrence of a 1 cm segment of Barrett's epithelium without dysplasia was present in two patients, both of whom had recurrent acid reflux due to failure of their antireflux procedure. Our results indicate that the combination of EAPC and antireflux surgery is an effective treatment option in patients with Barrett's esophagus with gastroesophageal reflux disease. Long-term follow-up of this therapy is necessary to evaluate its effect on cancer risk in Barrett's esophagus.
Research Interests: Gastroenterology, Biopsy, Humans, Female, Clinical Sciences, and 15 moreGeneral Anesthesia, Aged, Adult, Disease Progression, Electrocoagulation, Argon, Cancer Risk, Laparoscopy, Gastroesophageal Reflux, Gastroesophageal Reflux Disease, Esophagoscopy, Combined Modality Therapy, fundoplication, argon plasma coagulation, and Gastrointestinal surgery
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ABSTRACT
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Duodenogastric-esophageal reflux disease is directly linked to Barrett's esophagus and to the development of esophageal adenocarcinoma. Despite this link, little is known about the mutagenic potential of refluxed material on the... more
Duodenogastric-esophageal reflux disease is directly linked to Barrett's esophagus and to the development of esophageal adenocarcinoma. Despite this link, little is known about the mutagenic potential of refluxed material on the esophageal mucosa. We hypothesize that the reflux of gastric and duodenal content causes mutations in esophageal mucosa in vivo. Seven Sprague Dawley/Big Blue F1 lacI transgenic rats underwent esophagoduodenostomy (ED) to surgically create duodeno-gastric-esophageal reflux. Fourteen nonoperated rats served as negative (n = 7) and as positive (n = 7/methyl-N-amyl-nitrosamine [MNAN] intraperitoneally) controls. The animals were killed 16 weeks after operation or injection, the entire esophageal mucosa was harvested, and mutation frequency was determined through standard Big Blue Mutagenesis Assay. Gross esophagitis was evident in all operated animals. The frequency of lacI mutations in esophageal mucosal cells of animals with ED was significantly higher, n...
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Research Interests: Surgery, Adolescent, Endoscopy, General Surgery, Humans, and 15 moreFemale, Male, Lower Esophageal Sphincter, Posture, Clinical Sciences, Aged, Middle Aged, Adult, Muscle contraction, Hydrogen-Ion Concentration, Laparoscopy, Gastroesophageal Reflux, Gastroesophageal Reflux Disease, Hiatal hernia, and Esophagogastric junction
Research Interests: Inflammation, Microsurgery, Mutation, Mice, Animals, and 5 moreMale, Carcinogens, Clinical Sciences, Esophagus, and Adenocarcinoma
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Endorectal ultrasound is a well-established method for the preoperative staging of rectal tumors. This prospective study was performed to establish whether obtaining a biopsy before endorectal ultrasound has an influence on staging... more
Endorectal ultrasound is a well-established method for the preoperative staging of rectal tumors. This prospective study was performed to establish whether obtaining a biopsy before endorectal ultrasound has an influence on staging accuracy. Between 1990 and 2003, a total of 333 rectal tumors were examined preoperatively by using endorectal ultrasound. All patients underwent rectal resection, and the specimens were sent for histologic evaluation. Thirty-three were not biopsied, the remaining at various times before endorectal ultrasound. The chi-squared test or Fisher's exact test were used for statistical analysis to compare the accuracies. The overall staging accuracy was 71 percent but differed significantly (P = 0.004) between the groups as a function of time elapsed since biopsy. The best results were seen in tumors that were not biopsied before endorectal ultrasound, which were correctly staged in 85 percent of the cases. The least accurate staging (53 percent) was noted when endorectal ultrasound was performed in the third week after biopsy, mostly as a result of overstaging. Biopsy did not have a significant effect on nodal staging. Biopsy before endorectal ultrasound significantly affects its accuracy. To achieve the most accurate staging, biopsy should be performed after endorectal ultrasound. Endorectal ultrasound staging performed in the first week after biopsy is the second best option but should be interpreted with caution in the second or third week.
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Advances in the medical treatment of colorectal cancer patients have resulted in considerable improvements through the introduction of new cytotoxic drugs. The significant progress in molecular and tumour biology has produced a great... more
Advances in the medical treatment of colorectal cancer patients have resulted in considerable improvements through the introduction of new cytotoxic drugs. The significant progress in molecular and tumour biology has produced a great number of targeted, tumour-specific, monoclonal antibodies that are now in various stages of clinical development. Two of these antibodies, cetuximab (Erbitux) und bevacizumab (Avastin), directed against the epidermal growth factor receptor (EGFR) and the vascular epithelial growth factor (VEGF), respectively, have recently been approved for use in metastatic colorectal cancer. The combination of well-known and newly developed cytotoxic agents with monoclonal antibodies makes the medical treatment of colorectal cancer patients considerably more complex, but also provides additional therapeutic strategies for patients in advanced stages of disease.
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Duodenogastric reflux (DGR) was assessed with 24-hour gastric bilirubin monitoring in 345 patients (219 men; 49 +/- 13 years) with foregut symptoms and 41 healthy subjects (24 men, 28 +/- 5 years). Bilirubin exposure was measured as... more
Duodenogastric reflux (DGR) was assessed with 24-hour gastric bilirubin monitoring in 345 patients (219 men; 49 +/- 13 years) with foregut symptoms and 41 healthy subjects (24 men, 28 +/- 5 years). Bilirubin exposure was measured as percent time above absorbance level 0.25 and excessive DGR was defined above the 95th percentile of normal values (>24.8%). DGR was highest following Billroth II gastric resection (60 +/- 24%, N = 15). Patients after cholecystectomy (28 +/- 25%, N = 25), patients with gastroesophageal reflux disease (24 +/- 24%, N = 199), and patients with nonulcer dyspepsia (23 +/- 21%, N = 61) had a significantly higher exposure to DGR than healthy subjects (7 +/- 8%, P < 0.0001). In conclusion, gastric bilirubin monitoring is useful for the assessment of DGR specifically in symptomatic patients following gastric resection. Increased amounts of DGR may further be of clinical importance in patients with reflux disease or nonulcer dyspepsia and following cholecyste...
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Assessment of tissue vascularization with color Doppler (CD) can improve differential diagnosis of tumors. Until now, measurement of flow velocities is restricted to conventional duplex ultrasound of single vessels or semiquantitative... more
Assessment of tissue vascularization with color Doppler (CD) can improve differential diagnosis of tumors. Until now, measurement of flow velocities is restricted to conventional duplex ultrasound of single vessels or semiquantitative scoring of the vessel distribution in CD. We developed a new method for quantification of CD data in organs or tumors by statistical image analysis. Based on standardized image recording, data is acquired from the video output of any ultrasound scanner using a 24-bit color framegrabber in a personal computer. The digitized colors are recognized according to their position in the CD palette bar resulting in an 8-bit color image (number of identified pixels &gt; 99.9%). Within the region of interest, statistics of the detected flow patterns are calculated. The color pixel density and the mean color value varies between recordings of the same image during subsequent systolic peaks with a SD of 10% and 2%, respectively, and within different sections of the same organ or tumor with 25% and 10-50%. This analysis can be used for comparative or longitudinal studies and an objective evaluation of CD in complex vascular formations such as tumors. Its diagnostic impact has already been demonstrated in clinical studies.
Research Interests: Image Analysis, Ultrasound, Humans, Thyroid gland, Data Display, and 17 moreDifferential Diagnosis, Color Image, Clinical Sciences, Microcomputers, Information Storage and Retrieval, Longitudinal Studies, Longitudinal Study, Neoplasms, Clinical Study, Reproducibility of Results, Blood Vessels, Flow Velocity, Flow Pattern, Blood Flow Velocity, Region of Interest, Pulsatile Flow, and Video Recording
Laparoscopic gastric banding (LAGB) is the most popular surgical procedure for morbid obesity in Europe. Long-term complications like slippage of the band or pouch dilatation are well known and lead to reoperations in a substantial number... more
Laparoscopic gastric banding (LAGB) is the most popular surgical procedure for morbid obesity in Europe. Long-term complications like slippage of the band or pouch dilatation are well known and lead to reoperations in a substantial number of patients. In this study, results and follow-ups of patients with reoperations after gastric banding were analyzed. Between May 1997 and June 2006, 172 patients were treated with LAGB for morbid obesity. 41 of these patients underwent one or more band-related reoperations (female symbol = 32, male symbol = 9). Causes for and type of reoperation were analyzed. Weight loss and comorbidities were compared for different types of reoperations. There were no deaths following the reoperations. Band replacement (n = 18), band repositioning (n = 7), conversion to sleeve gastrectomy (SG, n = 2) and Roux-en-Y gastric bypass (RYGBP, n = 2) or band removal without any further substitution (n = 12) were performed as first reoperation. Seven patients had a second reoperation: RYGBP (n = 3), SG (n = 1), or band removal (n = 3). Median follow-up since reoperation was 56 months (range 7-113). Excess weight loss (EBWL%) of patients was 59.4% after RYGBP (n = 5), 45.1% after re-banding (n = 18), and 33.4% after SG (n = 2). Comorbidities were further reduced or even resolved after reoperation. Patients whose band was removed without subsequent bariatric procedures lost significantly less weight (n = 13, EBWL% 23.4) than patients with band replacement (n = 18, EBWL% 46.4, p = 0.04). Laparoscopic reoperation after LAGB is safe and feasible. Reoperation leads to further decrease of BMI and obesity-related comorbidities. Band replacement is a good option for patients with good weight loss after initial LAGB. Alternative procedures, preferably RYGBP, are required for cases of band failure. Overall, RYGBP appears to be the most effective option to induce further weight loss.
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Long-term complications after laparoscopic gastric banding (LAGB) are frequent, leading to reoperations for a substantial number of patients. It is not known whether esophageal motility or the lower esophageal sphincter (LES) play a role... more
Long-term complications after laparoscopic gastric banding (LAGB) are frequent, leading to reoperations for a substantial number of patients. It is not known whether esophageal motility or the lower esophageal sphincter (LES) play a role in the development of complications. The results of preoperative upper gastrointestinal (GI) testing were compared with outcome after LAGB. Before LAGB, 68 bariatric patients had esophageal manometry, endoscopy, and pH monitoring. For 61 of these patients (90% follow-up rate), the differences in weight loss, complications, and reoperation rate were retrospectively compared. Of these patients, 8.2% had a nonspecific motility disorder of the esophagus, 44.3% had an incompetent sphincter shown by manometry, and 17.5% had acid reflux shown by pH monitoring. Endoscopic evaluation showed esophagitis in 10.3% and hiatal hernia in 33.8% of the patients. Abnormal pH monitoring and endoscopic findings were not predictive for the long-term outcome or complications. The presence of an incompetent LES led to reoperation for a greater number of patients (44.4 vs. 14.7%; p = 0.01), especially if the band was placed using the pars flaccida technique. Endoscopy and pH monitoring do not predict outcome for gastric banding and therefore have no relevance in the selection of patients for gastric banding. Patients with an incompetent LES shown by manometry had a higher reoperation rate. If this finding can be confirmed, patients with LES incompetence may need another intervention.
Research Interests: Adolescent, Humans, Weight Loss, Female, Male, and 16 moreYoung Adult, Follow-up studies, Esophageal pH monitoring, Lower Esophageal Sphincter, Gastric banding, Clinical Sciences, Middle Aged, Gastrointestinal Endoscopy, Adult, Esophagus, Time Factors, Retrospective Studies, Prognosis, Surgical, Laparoscopy, and Predictive value of tests
Cancer of the cardia is now topographically classified into three types: type I, with the tumor center in the distal esophagus treated with subtotal esophagectomy; type II, arising at the gastroesophageal junction and treated with distal... more
Cancer of the cardia is now topographically classified into three types: type I, with the tumor center in the distal esophagus treated with subtotal esophagectomy; type II, arising at the gastroesophageal junction and treated with distal esophagectomy and either proximal or total gastrectomy; and type III, subcardial cancer treated with extended total gastrectomy. Our objective was to review the new classifications and compare the outcomes in patients grouped and treated according to these classifications. Seventy-four patients with cancer of the cardia--15 with type I, 30 with type II, and 29 with type III cancer--underwent surgical resection at our institution between 1992 and 1997. Postoperative complications, UICC stages, and survival (Kaplan-Meier) were compared. The majority of patients with type I (73%) or type II (53%) cancer had stage I or II tumors, but only 27% of patients with type III cancer had this tumor stage (P &lt; .05). Overall 30-day mortality was 4% and morbidity was 31%. Curative resections were performed in 73% (54 of 74) of the patients with 3-year survival rates of 72% (type I), 68% (type II), and 61% (type III). The recommended therapy for the different types of cancer of the cardia results in acceptable morbidity, mortality, and survival rates.
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Gastric cancer carries a poor prognosis even after curative resection (R0). Tumor progression in gastric cancer patients has been attributed to the persistence of disseminated tumor cells (DTC) in various body compartments as a sign of... more
Gastric cancer carries a poor prognosis even after curative resection (R0). Tumor progression in gastric cancer patients has been attributed to the persistence of disseminated tumor cells (DTC) in various body compartments as a sign of minimal residual disease, although the prognostic relevance of DTC is still unclear. In this study the prognostic relevance of DTC in the blood of gastric cancer patients was investigated. Venous blood samples of 70 cancer patients were taken intraoperatively before surgical manipulation and examined by reverse transcription-polymerase chain reaction (RT-PCR) for expression of cytokeratin 20 (CK20) as a marker for DTC. Tumor-related survival was analyzed using univariate and multivariate models assessing occurrence of DTC, residual tumor classification, and tumor stage. Median follow-up was 20 months (range 1-57 months). Twenty-eight of the 70 patients (40%) were CK20 positive. The prevalence of DTC in patients following R0 resection (15/41, 37%) was similar to that in patients with residual tumor (13/29, 45%, NS). Furthermore, expression of CK20 was independent of TNM stage. Univariate analysis of R0-resected patients revealed CK20 to be a marker for significantly shorter tumor-related survival (p = 0.0363). In a multivariate analysis, CK20 was an independent prognostic marker. Detection of CK20 had greatest impact for early tumor stages (T1 and T2, N0; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0032). Detection of DTC in venous blood of gastric cancer patients is an independent predictive marker of poor prognosis and thus could help to define patients for adjuvant therapy with this tumor entity.
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A rare complication of adjustable gastric banding is reported. A 65-year-old man developed recurrent vomiting, epigastric pain, and small-bowel obstruction 13 months after laparoscopic adjustable gastric banding for morbid obesity.... more
A rare complication of adjustable gastric banding is reported. A 65-year-old man developed recurrent vomiting, epigastric pain, and small-bowel obstruction 13 months after laparoscopic adjustable gastric banding for morbid obesity. Investigation revealed that the band had migrated completely into the gastric lumen and had passed far down the jejunum. The band was still connected by the tubing to the port chamber. By laparoscopy, the band was cut at the stomach, and removed via a jejunotomy. Postoperative course was uneventful. Complete band migration requires early removal of the band.
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Long-term outcomes of gastric banding regarding depression and predictors of change in depression are still unclear. This prospective, controlled study investigated depression and self-acceptance in morbidly obese patients before and... more
Long-term outcomes of gastric banding regarding depression and predictors of change in depression are still unclear. This prospective, controlled study investigated depression and self-acceptance in morbidly obese patients before and after gastric banding. A total of 248 morbidly obese patients (mean body mass index [BMI] = 46.4, SD = 6.9) seeking gastric banding completed questionnaires for symptoms of depression (Beck Depression Inventory) and self-acceptance. One hundred twenty-eight patients were treated with gastric banding and 120 patients were not. After 5 to 7 years, patients who either had (n = 40) or had not (n = 42) received gastric banding were reassessed. In the preoperative assessment, 35% of all obese patients suffered from clinically relevant depressive symptoms (BDI score &amp;amp;amp;amp;gt; or =18). The mean depression score was higher and the mean self-acceptance score was lower than those of the normal population. Higher preoperative depression scores were observed among patients living alone and who had obtained low levels of education. After 5 to 7 years, patients with gastric banding had lost significantly more weight than patients without gastric banding (mean BMI loss 10.0 vs. 3.3). Gastric banding patients improved significantly in depression and self-acceptance, whereas no change was found in patients without gastric banding. Symptoms of depression were more reduced in patients who lost more weight, lived together with a partner, and had a high preoperative depression score. Morbid obesity is associated with depressive symptoms and low self-acceptance. Gastric banding results in both long-term weight loss and improvement in depression and self-acceptance.
Research Interests: Psychometrics, Depression, Humans, Weight Loss, Female, and 17 moreMale, Follow-up studies, Body Mass Index, Beck Depression Inventory, Gastric banding, Obesity Surgery, Clinical Sciences, Self Concept, Questionnaires, Body mass index (BMI), Adult, Public health systems and services research, Morbid Obesity, Educational Status, Depressive Symptoms, Prospective Study, and Marital Status
In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB). 85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were... more
In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB). 85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were analyzed according to several possible predictive characteristics for success as the primary endpoint. Success was defined as excess body weight loss (EBWL) &amp;amp;amp;amp;amp;amp;gt;50% and no band removal. Median follow-up was 27 months (range 8-90 months). In total, median EBWL was 43% (-41 to 171.5%) with a decrease in BMI of 8.0 kg/m(2) (-9 to 35 kg/m(2)). Success rate was 37% (n = 26). These patients were compared to all other patients (n = 45). Significant success predictors were baseline absolute BW, EBW, BMI (p &amp;amp;amp;amp;amp;amp;lt; 0.01), BMI with a threshold value of 50 kg/m(2) (p = 0.02), and female sex (p = 0.02) as well as postoperative vomiting (p = 0.02), eating behavior and physical activity after LAGB (p &amp;amp;amp;amp;amp;amp;lt; 0.01). Baseline EBW and change in eating behavior after surgery were identified as independent predictors in multivariate analysis. Patients with a lower excess body weight who improve especially their eating behavior after surgery have the highest chance of success after LAGB.