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Biomedical subjects

A Klaus

Publications and source records attributed to A Klaus.

At least 19 recordsLinked to original sources
PubMed2004

Surgical revision after failure of laparoscopic adjustable gastric banding.

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.

Adolescent↗
PubMed2004

Adjustable gastric banding: assessment of safety and efficacy of bolus-filling during follow-up.

BACKGROUND: Individual band-filling on demand of the morbidly obese patient is a major advantage of adjustable gastric banding. An increasing number of patients results in an enormous amount of outpatient follow-up visits, which inspired us to compare a stepwise band-filling strategy with a single bolus injection 4 weeks after the operative procedure. METHODS: 40 consecutive patients were prospectively randomized in 2 groups. 20 patients (Group A) had stepwise band-filling during 6 monthly ambulant visits. 20 patients (Group B) had a bolus-filling 4 weeks postoperatively and had the next follow-up after another 5 months. Weight loss, complications and procedural costs during follow-up were compared. RESULTS: Patients of both groups did not differ in age, gender or preoperative BMI. There was no significant difference postoperatively in excess weight lost (EWL) after 9 months. Postoperative complications did not differ significantly. By means of bolus-filling, a 60% and 53% reduction in outpatient clinical work was achieved within the 6 and 9 months, respectively. CONCLUSION: Postoperative management after gastric banding takes advantage of a single bolus-filling during the first postoperative 6 months due to sufficient weight loss, low complication rate but significant reduction of personal, financial and logistic efforts.

Adult↗
PubMed2004

Ventral hernia repair in bariatric surgery.

BACKGROUND: Obesity is an important risk factor for perioperative complications including the development of ventral hernias. METHODS: This retrospective study comprises patients who underwent abdominal hernia repair simultaneously with or following implantation of a Swedish Adjustable Gastric Band(R) (SAGB). RESULTS: 9 out of 415 patients (2.2%) who received a SAGB between January 1996 and June 2001 underwent ventral hernia repair. In 6 patients, hernias preexisted from previous abdominal surgery at the time of the bariatric procedure, and another 3 hernias occurred at the median and left upper abdominal trocar position following SAGB placement. Median BMI at time of SAGB implantation was 44 (range 35-52), and at time of hernia repair was 36 (range 25-46). 2 hernias were repaired during SAGB placement, 3 during redo surgery, and 2 during abdominoplasty. In 2 patients, significant weight loss with loss of soft tissue support of the hernia sac led to recurrent episodes of small bowel obstruction necessitating emergency repair. Repair included direct defect closure in 7 patients and sublay polypropylene net implantation in 2 patients. Recoveries have been uneventful without wound infections or recurrence in all patients after a median follow-up of 34 months (range 13-69). CONCLUSION: In morbidly obese patients, the optimal management and timing of incisional hernia repair should weigh the risk of recurrence and perioperative complications against the risk of hernia-associated complications.

Adult↗
PubMed2004

[Pathology of small intestine transplantation].

Small bowel transplantation is being increasingly performed to treat patients with irreversible intestinal failure or short bowel syndrome. Worldwide approximately 100 transplantations are currently performed per year. Technical advances and new immunosuppressive strategies adopted during the last 10 years have significantly improved the quality of live and survival rate of the patients. The 5-year survival rate is currently around 60%. However, the procedure still bears significant live threatening risks. Mayor problems include surgical complications like anastomotic leakage or peritonitis, acute allograft rejection, systemic infection and in later stages loss of graft function due to chronic rejection. Acute rejection is common after intestinal transplantation. It may occur any time after transplantation and is seen in 50%-80% of the patients. The characteristic changes are enterocyte apoptosis in the crypts, cryptitis and mononuclear cell infiltration with activated lymphocytes. Severe cases may reveal ulcerations or even sloughing and widespread exfoliation of the epithelium and are almost invariably associated with graft loss. The histopathological abnormalities may be patchy and occur in grossly normal mucosa. Therefore, multiple biopsies should be generally sampled for histology. Acute rejection must be distinguished from infections in particular opportunistic viral infections caused by Cytomegalovirus (CMV) or Adenovirus as well as from Epstein-Barr virus-related B-lymphocyte proliferations. Differential diagnosis also includes preservation injury and ischemia resulting in damage of the mucosal surface epithelium. Long-term graft function and survival are now increasingly determined by chronic rejection. The hallmarks of chronic rejection are obliterative arteriopathy of mesenterial vessels and progressive fibrosis of the transplant including its mesentery.

Graft Rejection↗
PubMed2003

Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects.

BACKGROUND: This pilot study evaluated the role of the DaVinci operation robot for laparoscopic antireflux surgery. PATIENTS AND METHODS: A robot-assisted laparoscopic Toupet-fundoplication was performed on nine consecutive patients with severe gastroesophageal reflux disease using the DaVinci robot system. The operative procedure was performed in the same way as for the conventional laparoscopic procedure. Clinical assessment and endoscopic and manometric follow-up investigations were performed 6 months after surgery in six of the patients. RESULTS: The mean robotic operative time was 173 min (120-235). A mean of 25 min (12-45) was required to establish the pneumoperitoneum, to set the trocars, and to place the robot arms. There were no intraoperative complications. Six months after surgery none of the patients suffered from reflux symptoms and none of the patients had acute esophagitis. Postoperatively one patient complained of mild transient dysphagia. However, persistent dysphagia was not found in any of the patients. One further patient complained of mild bloating. No other side effects occurred. Manometrically there was a significant improvement in the function of the lower esophageal sphincter. CONCLUSIONS: The robot-assisted partial posterior fundoplication is a safe procedure and provides a high-quality three-dimensional camera image that is superior to that with the conventional laparoscopic device. The handling of the instruments is precise, and intracorporeal suturing and knot tying is much easier than without the robotic technique. The procedure allows for an accurate approximation of the hiatal crura and for precise construction of the fundic wrap. However, robotic surgery is expensive and the setup of the system is time consuming at present.

Adult↗
PubMed2003

Colonoscopically placed hemoclips as treatment for massive appendiceal stump bleeding.

Massive bleeding from an appendiceal stump is a rare but occasionally seen severe complication. The bleeding may drain into the abdominal cavity, the retroperitoneum, or the digestive tract. Gastrointestinal hemorrhage may occur early or even years after appendectomy. The typical management includes ligation of the bleeding vessel or cecal resection done by either emergency laparotomy or laparoscopy. An alternative treatment option would be an angiographic embolization of the bleeding vessel. We report on a 33-year-old woman with severe lower gastrointestinal hemorrhage 1 day after an apparently uncomplicated appendectomy for acute phlegmonous appendicitis with ligation and invagination of the appendiceal stump. Hemoglobin level dropped to 6.3 g/dl and made blood transfusion necessary. The cause of bleeding was a small intramural branch of the appendiceal artery at the appendiceal stump, which was diagnosed by emergency colonoscopy. The hemorrhage could be controlled endoscopically by placing hemoclips on the distinct vessel in combination with a biological tissue adhesive. The patient recovered thereafter without further intervention. Endoscopic clipping for the treatment of appendiceal stump bleeding is a novel, effective, and safe procedure. Thereby, conventional emergency laparotomy or laparoscopy or angiographic embolization can be avoided.

Adult↗
PubMed2002

Barrett's esophagus in patients with gastroesophageal reflux disease. Medical therapy or antireflux surgery?

Barrett's esophagus is the most serious form of gastroesophageal reflux disease. It may develop due to uncontrolled chronic duodenogastroesophageal reflux and represents a premalignant abnormality. The question of the development of Barrett's esophagus and the progression to adenocarcinoma of the esophagus is addressed by comparison of the data available in the literature. A retrospective review of the literature on the outcome of GERD patients after surgical and medical therapy, is made. Surgical therapy is able to eliminate reflux of gastric and duodenal contents and therefore seems to be superior over medical therapy in the prevention of Barrett's esophagus and its progression to invasive cancer. Surgery should be considered in all Barrett's patients especially in young patients, patients with large hiatal hernia, increasing drug doses or noncompliance to medical therapy.

Adenocarcinoma↗
PubMed2001

Laparoscopic antireflux surgery for supraesophageal complications of gastroesophageal reflux disease.

Gastroesophageal reflux disease can result in such supraesophageal complications as hoarseness, sore throat, cough, bronchitis, asthma, recurrent pneumonia, intermittent choking, chest pain, and ear pain. Appropriate patient care involves careful evaluation to decide on medical or surgical therapy. Preoperative testing must include endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry. Additional evaluations, such as barium swallow, chest x-ray, bronchoscopy, and sinus radiographs, may be required. Medical treatment improves gastroesophageal reflux and supraesophageal symptoms. However, surgical therapy seems to provide better long-term results. A profile that predicts the best response to medical therapy has not been identified, although the best results with surgery are achieved in patients with nocturnal asthma, onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical treatment.

Fundoplication↗
PubMed2001

Safety and long-term outcome of laparoscopic antireflux surgery in patients in their eighties and older.

BACKGROUND: The elderly have more severe reflux disease and paraesophageal hernias than younger patients, leading to a high failure rate of medical therapy. Laparoscopic antireflux surgery has an overall mortality of 0.1% and a low morbidity, making it a safe and beneficial procedure for the elderly. METHODS: We performed a retrospective study of octo- and nonogenerians with a mean follow-up of 3.1 years after laparoscopic fundoplication. Thirty (3.5%) patients who were in their eighties or older are reported. Preoperative symptoms, esophageal testing, postoperative symptoms, and satisfaction rate were analyzed. RESULTS: Fifty-seven percent of patients had paraesophageal hernias. Mean duration of procedures was 146 +/- 49 min, blood loss was 76 +/- 101 ml, and hospitalization was 2.2 +/- 1.0 days. There was one conversion to laparotomy, two intraoperative complications, and no deaths. Follow-up data were available in 93% of patients. Mean follow-up time was 3.1 years. Two died of unrelated causes. At follow-up 96% stated that their surgical outcome was satisfactory. Two patients were suffering from severe symptoms. Overall well-being at follow-up was 7.5 (range 3-10) on a 10-point scale in comparison to 2.2 (range 1-5) before surgery (p = 0.03). CONCLUSION: Laparoscopic surgery is a good option for the treatment of severe gastroesophageal reflux disease in octo- and nonagenarians.

Age Factors↗
PubMed2001

A new biliodigestive anastomosis technique to prevent reflux and stasis.

BACKGROUND: The Roux-en-Y procedure for biliodigestive drainage is most widely accepted, but 10% to 15% of patients postoperatively suffer from a blind-loop syndrome or cholangitis due to motility disorders. A new biliodigestive technique is evaluated in a rat model to prevent these complications. METHODS: This experimental study in Wistar rats compares the Roux-en-Y technique with a new biliodigestive anastomosis creating a jejunal loop with luminal occlusion. Clinical parameters, small bowel motility, bacteriologic growth, and liver histopathology were evaluated in native and postoperative animals within a study period of 180 days. RESULTS: Both operative procedures were well tolerated. After 6 months intense fibrosis of the liver and high-grade purulent cholangitis were observed in animals in the Roux-en-Y group. In these animals enterobacter and enterococci overgrowth was found. Myoelectric small bowel recordings revealed significant impairment of slow-wave frequency, aboral velocity, and action potentials (percentage of phase III) in Roux-en-Y animals. CONCLUSIONS: Motility disorders after conventional Roux-en-Y biliodigestive anastomosis are pivotal for histomorphological damage and infectious findings and can be prevented by using the new technique to create a jejunal loop with luminal occlusion.

Anastomosis, Roux-en-Y↗
PubMed2001

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate whether Barrett's metaplasia may develop despite effective medical therapy. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. METHODS: Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. RESULTS: Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. CONCLUSIONS: Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2001

Rationale for surgical therapy of Barrett esophagus.

Barrett esophagus has malignant potential and seems to be an acquired abnormality. It is associated with chronic gastroesophageal reflux disease and represents its severest form. The literature comparing medical treatment with antireflux surgery was reviewed. Questions regarding the advantages of surgery, who should undergo surgery, whether surgery can change the course of Barrett esophagus, the change in cancer risk, who needs surveillance, and cost-effectiveness were addressed. The incidence of developing Barrett cancer was 1 in 145 patient-years in reviewing 2032 patient-years of medical therapy compared with 1 in 294 patient-years in reviewing 4122 patient-years after surgery. Median follow-up time in the 2 groups was 2.7 years in the medically treated patients and 4.0 years in the surgically treated patients. Surveillance of Barrett esophagus is required irrespective of treatment. Laparoscopic antireflux surgery was found to be cost-effective after 7 years. Although these data do not prove that surgery is superior to medical treatment in the prevention of cancer related to Barrett esophagus, we found a tendency for surgery to be better than medical therapy to prevent the development and progression of Barrett carcinoma.

Barrett Esophagus↗
PubMed2001

Indications for antireflux surgery in Barrett's.

One of the most common complications of gastroesophageal reflux disease is Barrett's esophagus. Medical therapy for this condition is not very effective and does not seem to be able to control the occurence and progression of the disease. In contrast, there is some evidence that effective antireflux surgery does have a slowing effect on the occurence and the progression of Barrett's esophagus. There is also some evidence that the progression of Barrett's to high-grade dysplasia and carcinoma is less after antireflux surgery than during medical therapy. Antireflux surgery should be considered in patients with Barrett's who have a large hiatal hernia, dysplasia, a weak lower esophageal sphincter pressure, failed medical therapy, noncompliance to medications, and young age.

Barrett Esophagus↗
PubMed2001

Congenital diaphragmatic hernia in adults.

Congenital diaphragmatic hernia is rarely seen in adults. A review of the literature is presented, and 2 additional cases of Morgagni and Bochdalek hernias are presented. They were both repaired with the laparoscopic approach.

Adult↗
PubMed2000

[Cytomegalovirus infection after heart transplantation. Retrospective analysis of an antiviral CMV prevention].

OBJECTIVE: Cytomegalovirus (CMV) infection is the most common viral infection in the early period after heart transplantation (HTX) and causes a significant morbidity and mortality. Although controversial, CMV is related to acute and chronic allograft rejection and to the development of graft vascular disease. It therefore plays an important role in the long-time outcome after solid organ transplantation. PATIENTS AND METHODS: 45 patients received a new heart between 1.1.97 and 31.12.1998. All of them were enrolled postoperatively in three-month antiviral prophylaxis (Cymevene). Only those patients were excluded from prophylaxis who were seronegative for CMV and received hearts from seronegative donors (n = 6). The pp65 antigenaemia assay and the murex hybrid capture CMV DNA assay on peripheral blood as well as the early antigen detection in the urine were used for CMV detection and also for monitoring. RESULTS: A total number of 580 assays were analysed (12.9 assays/patient). 561 tests (96.7%) were negative, 19 (3.3%) were positive. For CMV testing the pp65 antigenemia assay was used in 64.1%, the murex hybrid capture CMV DNA assay in 18.4% and the urine early antigen detection in 17.4%. Three patients (6.7%) developed viraemia during the first 3 postoperative months. Two patients (4.4%) suffered from CMV infection 8 and 9 months after heart transplantation and had to be treated with antiviral agents. Three patients (6.7%) died early after transplantation, but none had a CMV infection. CONCLUSION: Prevention of CMV disease was successful with three months of antiviral CMV prophylaxis after HTX. Asymptomatic viraemia during the prophylaxis period did not lead to tissue invasive disease. It is possible to carry out rapid CMV detection and CMV monitoring with the commercially available antigenaemia assays.

Adolescent↗
PubMed2000

Manometric components of the lower esophageal double hump.

BACKGROUND/AIMS: The lower esophageal sphincter manometry of patients with hiatal hernia often displays a double hump configuration. It seems that this is due to gastric herniation above the high-pressure zone of the crura. This study examines this manometric phenomenon in patients with hiatal hernia and relates it to the lower esophageal antireflux barrier. METHODS: Manometric and 24-hour pH studies of 68 consecutive patients with suspected gastroesophageal reflux disease were analyzed to obtain information regarding the double hump and acid reflux. RESULTS: The findings of a manometric double hump correlated well with the presence of a hiatal hernia of >5 cm. The overall length of the sphincter complex was greater in patients with a double hump, but the length below the respiratory inversion point was constant. Resting pressures at the respiratory inversion point were significantly lower than those measured at either high-pressure zone. The location of the respiratory inversion point was seen most commonly at the superior margin of the distal high-pressure zone. Double hump patients with a negative acid reflux score were found to have higher pressures in the distal high-pressure zone than those patients with acid reflux. CONCLUSIONS: The two high-pressure zones comprising the manometric double hump represent the crural and muscular components of the lower esophageal sphincter. Descriptive information regarding the double hump phenomenon is given, and the importance of the crural component of the lower esophageal sphincter in preventing acid reflux is stressed.

Adult↗