Advanced Surgery

 7 year follow-up results were published recently of a swedish prospective randomized study comparing168 Patients following laparoscopic (TEP) and open (Lichtenstein) hernia repair.  The rate of recurrence was 5 % in both groups. However, chronic testicular pain occurred in 14% after laparoscopic repair as campared to 1% in the Lichtenstein group.  Four TEP cases reqired reoperations for complications but no Lichtenstein patient.Hallen M, Bergenfelz A, Westerdahl J: Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long-term follow-up of a randomized controlled trial. Surgery 2008; 143: 313-7

Just to keep in mind : Consensus statement of the Bangkok Conference of the International Asociation for the Study of Obesity (IASO) ”… There is compelling evidence that prevention of weight regain in formerly obese individuals requires 60-90 minutes of moderate intensity activity or lesser amounts of vigorous intensity activity. ….. A good approach for many individuals to obtain the recommended level of physical activity is to reduce sedentary behaviour by incorporating more incidental and leisure-time activity into the daily routine. Political action is imperative to effect physical and social environmental changes to enable and encourage physical activity. Settings in which these environmental changes can be implemented include the urban and transportation infrastructure, schools, and workplaces.”

Although very effective in the treatment of morbid obesity gastric bypass is associated with perioperative complications that may be life-threatening. Based on a single institution experience of 2075 cases a group from Duke University, Durham, NC, have proposed a prognostic score for the assessment of mortality risk following bariatric surgery. This Obesity Surgery Mortality Risk Score (OS-MRS) considers five preoperative characteristics including weight (BMI equal or greater than 50), male gender, hypertension, age and prevalence of risk factors for pulmonary embolism (i.e. history of thromboembolism, vena cava filter, pulmonary hypertension). This risk score was validated in a population of 4431 patients undergoing gastric bypass at 4 centers.There were 33 deaths ( 0.7% mortality) within 90 days following surgery in the validation cohort. Patients with a score of 0 - 1 points (n=2164; class A) had a mortality of 0.2%, class B (2-3 points; n= 2142) 1.1%, whereas three deaths occurred in the 125 patients (2.4%) with 4 - 5 points of the score (class C).25 of the 33 deaths occurred within 30 days after the operation, eight between day 31 and 90. The causes of death were pulmonary embolism (n=10), cardiac event (n=9), gastrointestinal leak (n=7) and “unknown/sudden” (n=5).The fous centers contributed an average of 1100 cases to the study (range: 816 to 1320). It is not known, whether the results in the study do also apply to centers performng this surgery less frequently.DeMaria, Eric J. et al.Annals of Surgery. 246(4):578-584, October 2007

The Times October 15, 2007

Ministers are drawing up plans for a concerted fight against obesity as they believe that there is a looming public health crisis to rival that of climate change.

Alan Johnson, the Health Secretary, said that efforts to promote exercise and healthy eating had to go “further and faster” in response to the stark findings of a new government study.

The Foresight research, commissioned in 2005 to help ministers to understand the scale of the problem, gave warning that half the population would be obese within 25 years if current trends continue.

Some 86 per cent of men are expected to be overweight within 15 years and 70 per cent of women within 20 years, Professor Klim McPherson, of Oxford University, and Tim Marsh, of the National Heart Foundation, predict.

Mr Johnson said that the Government could not afford to allow the problem to deepen and is set to ask the Food Standards Agency to investigate the use of unhealthy “trans-fats” in fast food. “For the first time, we are clear about the magnitude of the problem: we are facing a potential crisis on the scale of climate change, and it is in everybody’s interest to turn things round,” he said.

Mr Johnson added: “There is no single solution to tackle obesity and it cannot be tackled by government action alone. We will only succeed if the problem is recognised, owned and addressed at every level and every part of society.”

Ed Balls, the Children’s Secretary, said schools should scrap “embarrassing” gym kits and offer a wider range of activities, such as yoga and frisbee, to encourage children to be healthy. “If the kit is awful or embarrassing it’s much more likely the kids will forget to bring it,” he told The Guardian.

Extra cash set aside in Tuesday’s Comprehensive Spending Review will fund a long-term obesity action plan.

Übergewicht, das ist ein BMI zwischen 25 und 30 und Fettsucht (BMI über 30) sind mit einem erhöhten Risiko für gastro-ösophagealem Reflux verbunden [Jacobson et al. Body-mass index and synptoms of gastroesophageal reflux in women. N Engl J Med 2006 Jun1; 354:2340-8]. Der Druck innerhalb des Magens steigt mit zunehmendem BMI, und induziert vermehrt spontane Relaxationen des unteren Speiseröhren – Schließmuskels [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=16530504&dopt=AbstractPlus]. Jüngste Untersuchungen haben nun gezeigt, dass nicht so sehr das subkutane Fett, sondern das abdominell gelegene viszerale Fett dafür verantwortlich ist [El-Serag HB et al. Obesity increases oesophageal acid exposure. Gut 2007 Jun; 56:749-55 ]. Bei 206 Patienten wurde eine 24 h pH-Metrie und Größe, Gewicht und Bauchumfang erhoben. Die Anzahl und Länge der Refluxepisoden waren bei Fettsucht vermehrt, und korrelierten vor allem mit dem Bauchumfang.

Das heißt, besonders die typische Fettverteilung beim metabolischen Syndrom ist für den Reflux verantwortlich, der sich in Form von Sodbrennen und Regurgitation äußert. Reflux, der mit einem erhöhten Bauchumfang assoziiert ist, neigt auch besonders dazu, mit den schweren Veränderungen wie dem Barrett-Ösophagus einher zu gehen, die als Vorstadium des Speiseröhrenkrebses bekannt sind [El-Serag HB et al. Abdominal Obesity and the Risk of Barrett’s Esophagus Am J Gastroenterol 2005 Oct ; 100:2151-6] .

Ein großer Bauchumfang ist also mit der Neigung zu Reflux assoziiert, zusätzlich zu seiner grundlegenden Bedeutung als Risikofaktor für gestörte Glucosetoleranz, vermehrte Insulinresistenz, Diabetes mellitus, Dyslipidämie und Hochdruck.

Der Magen-Bypass, eine erprobte Option gegen Fettsucht, eliminiert den gastro-ösophagealen Reflux komplett. Darüber hinaus beseitigt er in der Mehrzahl der Fälle einen Diabetes mellitus, vermutlich über eine vermehrte postprandiale Freisetzung von GLP-1 und infolgedessen einer Hemmung der hepatischen Glucoseproduktion. Die laparoskopiische Fundoplicatio ist eine langfristig wirksame Alternative zur pharmakologischen Therapie der Refluxkrankheit. Liegt bei Patienten, die für eine Fundoplicatio infrage kommen, eine Fettsucht (BMI≥30), ein metabolisches Syndrom, oder gar ein manifester Diabetes vor, so sollte meiner Meinung nach die Möglichkeit eines gatric bypass erwogen werden.
Prof. Dr. Johannes Miholic

On August 9 2007 the FDA announced to investigate on possible adverse effects of omeprazol and esomeprazol. In May 2007 Astra-Zeneca, the producer of these compounds gave notice to the FDA about two prospective randomized trials comparing longterm treatment of gastro-esophageal reflux with proton pump inhibitors with Nissen fundoplication: significantly fewer cardiovascular events were found in the operative group.The protective effect of fundoplication could be related to the enhanced postprandial release of GLP-1, which has been shown to be associated with the faster gastric emptying in patients having undergone Nissen fundoplication. GLP-1 which is released from the distal small bowel and  stimulates insulin secretion, and inhibits glucagon release. It attenuates hepatic glucose production and may therefore be one of the mechanisms by which non insulin dependent diabetes mellitus is improved or cured after gastric bypass for obesity. GLP-1 also reduces appetite , and may thus contribute to reduce the risk for cardiovasculac morbidity. Inded, a mean weight loss of 3,9 kg was observed by Neumayer et al. within 3 Months after Nissen fundoplication, which remained unchanged at 12 months postoperatively (Neumayer et al. Surgical Endoscopy 2004).Accelerated gastric emptying followed by enhanced postprandial GLP-1 release was found in patients having undergone fundoplication for gastro-esophageal reflux disease (Miholic et al. Surgical Endoscopy 2007).Altered glucose metabolism as a consequence of enhanced postprandial GLP-1 release might explain the lower cardiovascular morbidity in the fundoplication subjects of the two trials, and, if comfirmed by further evidence, is a strong argument for fundoplication in the long-term treatment of gastro-esophageal reflux. Prof. Dr. Johannes Miholic