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Morbid obesity affects the function of the transplanted heart either directly, by damaging many elements that affect cardiac function or indirectly, by the initial appearance or worsening of co-morbidities that affect the heart. Bariatric surgery is the most effective treatment for a significant and sustained decrease in weight and it leads to the disappearance of co-morbidities such as diabetes, hypertension and dyslipidemia in high rates. These diseases can damage the blood vessels of the graft and impair its function. We report a case study of a 47-year-old morbidly obese male (BMI 36 kg/m2] who underwent heart transplantation three years previously, developed gradual weight gain and symptoms of aggravating heart failure. Coronary artery disease in the implanted heart was diagnosed. Clinically, he started suffering from shortness of breath and chest pain during minimal effort. In addition, he also suffered from high blood pressure and kidney failure. Laparoscopic sleeve gastrectomy was successfully performed and he was discharged four days later. On follow-up the patient has lost 35 kg. His present weight is 74 kg (BMI 25.7). All symptoms of heart failure improved and oral medications for hypertension and heart failure were withdrawn. Our conclusion is that it is justified to consider bariatric surgery in heart transplant recipients suffering from morbid obesity, as long as the long-term benefit outweighs the surgical risk. The decision to perform bariatric surgery should be made by a multidisciplinary team and the operation should take place at a center with extensive experience in bariatric surgery.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently considered the gold standard treatment for morbid obesity. The learning curve for this procedure is about 100 cases, and it is considered the most important factor in decreasing complications and mortality. We present our experience and learning curve with LRYGB., Methods: The data was collected prospectively. All patients with primary LRYGB between March 2006 and April 2014 were included. Only patients with full data on demographics, length of stay, operating time, and complications were included in the study., Results: Five hundred and eleven patients underwent a LRYGB. Ninety five of them underwent a redo RYGB (conversion), and were excluded. Of the remaining 416 patients, full data was available for 326 and the statistical analysis refers to this group. The complication rate was available for all patients who were included in the study. The mean age and body mass index were 43 years (14-76 years) and 42.8 kg/m2 (34-76) respectively. The mean duration of surgery was 86 minutes (40-420). In the first 100 patients, operating time was 148 min, while in the last 125 patients it was 75 min. The major perioperative complication rate was 7.7%. Of 4 leaks (0.95%, 3 were encountered in the first 100 operations, and one in the following 316 (3% and 0.3% respectively). The mean length of stay was 2.2 days (1-46). None of the patients stayed in the intensive care unit. There was no mortality., Conclusions: LRYGB is very safe. We confirm that the learning curve for this procedure is more than 100 cases. Appropriate training is crucial.

The number of people suffering from surgery and obesity in the western world is constantly growing. In 1997 the World Health Organization (WHO) defined obesity as a plague and one of greatest public health hazards of our time. The National Institution of Health (NIH) declared that surgery is the only long-term solution for obesity. Today there are four different types of bariatric surgery. Each variation has different implications on the nutritional status of bariatric surgery patients. Bariatric surgery candidates are at risk of developing vitamin and mineral nutritional deficiencies in the post-operative stage, due to vomiting, decrease in food intake, food intolerance, diminution of gastric secretions and bypass of absorption area. It is easier and more efficient to treat nutritional deficiencies in the preoperative stage. Therefore, preoperative detection and correction are crucial. Blood tests before surgery to detect and treat nutritional deficiencies are crucial. In the postoperative period, blood tests should be conducted every 3 months in the first year after operation, every six months in the second year and annually thereafter. Multivitamin is recommended to prevent nutritional deficiencies in all bariatric surgery patients. Furthermore, iron, calcium, Vitamin D and B12 are additionally recommended for Roux-en-Y Gastric Bypass patients. Patients with Biliopancreatic diversion and Duodenal Switch should also take fat soluble vitamins.

The incidence of type 2 diabetes mellitus is rising. It presently affects more than 150 million people worldwide, and 7.5% of the population of Europe suffer from this disease. This is partially explained by an increase in the prevalence of obesity. Less than 10% of the diabetic patients achieve appropriate control of their illness. For over a decade, it has been observed that the resolution of type 2 diabetes is an additional outcome of surgical treatment of morbid obesity. Moreover, it has unequivocally been shown that, postoperatively, diabetes-related morbidity and mortality have significantly declined. This improvement in diabetes control is long lasting, and was well documented postoperatively for at least 16 years. Two procedures, the Roux-en-Y gastric bypass (RYGB) and the biliopancreatic diversion (BPD), are more effective treatments for diabetes than other procedures. They are followed by normalization of concentrations of plasma glucose, insulin and glycosylated hemoglobin in 80-100% of morbidly obese patients. Studies have shown that results return to euglycemia and normal insulin levels occur within days after surgery, long before any significant weight loss occurs. This fact suggests that weight loss alone is not a sufficient explanation for this improvement. Other possible mechanisms effective in this phenomenon are decreased food intake, partial malabsorption of nutrients, and anatomical alteration of the gastrointestinal tract, that incites changes in the incretin system, which in turn, affect glucose balance. Better understanding of those mechanisms may lead to the discovery of new treatment modalities for diabetes and obesity.

WHO has listed obesity as a disease condition in its International Classification of Disease since 1979 and has assigned obesity a specific ICD-9, clinical modification code of #278.00, and morbid obesity, code #278.01. About 95% of those conservatively treated for morbid obesity will remain at the same weight or even gain weight during 5 years of follow-up. In 1991 an NIH Consensus Conference Panel convened and recommended that morbidly obese patients be offered an operative treatment for their disease. The weight loss mechanism of the bariatric operations is not clear, but the presumed effects are gastric restriction of food intake, malabsorption of the nutrients achieved by intestinal bypass, and secretion of different neuropeptides, that cause depression of the appetite and change in the metabolic rate. Restrictive operations are considered simpler and safer in terms of surgical performance and short term risks, but their efficacy is inferior to the malabsorptive ones. The latter are larger in regard to surgical extent, may cause more metabolic derangements, but produce more solid and long-lasting weight loss. The operation should be tailored to the candidate taking into consideration sex, age, health-related conditions, medications that are being taken, eating habits, and risks and benefits of every specific procedure. It is advisable that a bariatric surgery candidate undergo a thorough preoperative evaluation by a multidisciplinary team including a surgeon, a dietician, a psychology specialist, an internist or an endocrinologist, and other subspecialties as needed. A bariatric patient should maintain a life-long follow-up.

Blunt abdominal trauma is a common cause for admission of casualties to emergency departments and trauma units. The most commonly involved organs during blunt abdominal trauma are solid organs such as the spleen and the liver. Small bowel injuries caused by blunt abdominal trauma are relatively rare. The diagnosis of small bowel injuries is frequently delayed. The delay in diagnosis may contribute to relatively high rates of morbidity and even mortality. Physical examination of the patient is suggestive for injury in only half of the patients and further diagnostic modalities are usually needed. In this article we present two patients who were involved in motor vehicle accidents and underwent operations in our medical center because of small bowel injuries. We also present the current medical literature regarding this pathology.

Background: Low anterior resection, colo-anal anastomosis with anal sphincters preservation has become the routine procedure for the treatment of low rectal cancer. This method avoids the need for a permanent colostomy without compromising oncological principles. However, many of these patients experience symptoms of fecal frequency, urgency and variable degree of incontinence. Improvement with the functional results has been reported in patients in whom continuity has been restored by means of colonic j pouch., Aim: To compare the outcome of anterior resection and colonic pouch anal anastomosis (CPAA) with the conventional straight coloanal anastomosis (SCAA)., Material & Methods: The files of patients who underwent anterior resection with CPAA or SCAA between 1994-2001 were analyzed retrospectively. Patients filled out an updated questionnaire regarding their functional outcome., Results: Thirty nine patients underwent CPAA and 42 SCAA. Mean follow-up was 31 months. There was no perioperative mortality and the rate of complications was similar in the two groups. Bowel movements per 24 hours were 4.2 and 6 in the CPAA and the SCCA groups respectively. The bowel movements during night were 0.4 and 1.5 respectively. Sixty percent of patients after CPAA had 3 or less bowel movements per 24 hours as compared to 44% of patients after SCAA. Continence scores were 3.9 and 3.5 in patients after CPAA and SCAA respectively. Seventy two percent of patients after CPAA reported continence scores of 4 or more as compared to only 51% of patients in the SCAA group., Conclusion: Our results confirm previous reports that anterior resection and CPAA improves the functional outcome and quality of life after sphincter saving operation for low rectal cancer.