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A currently unsolved problem of open inguinal hernia repair (IHR) is chronic postoperative inguinal pain (CPIP), which affects 10–12% of patients after IHR. In the present paper, we explored the results of a newly designed partially absorbable mesh made of polypropylene and polylactic acid (HybridMesh®) for open hernia repair and its impact on postoperative safety, efficacy, comfort and pain. A prospective multicentric pilot trial was conducted in third-referral centers across Italy (n = 5). Inclusion criteria were unilateral primary inguinal hernia in patients of both genders and BMI

Hernia and Abdominal wall repair represents one of the surgical environments where knowledge is the real key to success, not the dissection of anatomic plane as happens in general surgery but the correct and effective use of anatomic structures represents the true ability of hernia surgeons. During the past years, several authors have left their names attached to anatomical structure and their variants testifying a great interest in the understanding of the pathological processes and modifications responsible of an abdominal wall defect. Today the interest in this field has raised more and more, thanks to the availability of new technologies, new approaches, and actually new procedures that push further the research in this area. It’s interesting to note that, on one hand, the need for a detailed knowledge of inguinal region has been flattened by the use of meshes, because of the reduced dissection in comparison to traditional tissue repairs. On the opposite side, the rise of Abdominal Wall Reconstruction concepts has been taken to the extreme of the concept of tenotomy and invented new anatomical routes and spaces for the surgeons. The aim of the present chapter is to easily describe these anatomical spaces and offer to the readers some tips and new insights to begin the route of abdominal wall anatomy.

Background The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. Methods The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. Results The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. Conclusion The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.

Several years have passed from the last time we read Irving Lichtenstein’s Hernia Repair Without Disability published in 1986 [1], and, despite changes and “corruptions” introduced by different authors during the years, the technique described by Lichtenstein still shows its value standing still and valid in the present days. The concept of tension-free repair for inguinal hernia represents one of the turning points of abdominal wall surgery: it was a paradigm shift from traditional tissue repair to modern mesh repair from the technical, physiopathological, and organizational standpoint.

Parastomal hernia (PH) is the most frequent complication associated with the presence of a colostomy [1]. According to EHS [2], a PH can be defined as an abnormal protrusion of the contents of the abdominal cavity through the abdominal wall defect created during placement of a colostomy, ileostomy, or ileal conduit stoma. The incidence of the disease is variably depicted in current literature biased by the retrospective nature of most of the studies. In recent years thanks to well-conducted RCTs, a clearer picture of the problem has been defined. Considering control arms of RCTs on mesh prophylaxis, the true overall incidence of PH has been estimated to be 55%, with a follow-up ranging from 10 to 80 months [3]. When analyzing time pattern of development, mainly in retrospective studies, it has been showed [4] that the risk of hernia development remains nearly constant over time, confirming the degenerative and iatrogenic nature of the condition. No direct study has ever compared directly techniques of construction, so there’s some form of uncertainty with respect to hernia rates among different type of ostomy. An overview of the literature suggests that end colostomy is associated with the highest incidence of parastomal hernia. Loop ileostomy was associated with a parastomal hernia incidence of 16% at 4 months in a RCT, where diagnosis was done during surgery for continuity restoration [5]. A similar incidence was reported in a case series with a clinical diagnosis of parastomal hernia at a mean follow-up of 9 years [6].

Highlights • Difficult diagnosis due to the paucity of symptoms and atypical radiological findings. • Primary site of infection was not detected. • Splenectomy is the best therapeutic choice in case of splenic abscess., Introduction Isolated splenic abscess is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is non-specific and the diagnosis is often delayed. Ultrasonography and CT scan are the gold standard. The treatment is still controversial: antibiotic therapy, percutaneous drainage (PCD) or splenectomy. Case presentation We present the clinical case of a patient, admitted to our Department because of abdominal pain, without fever. The preoperative radiological assesment showed three intrasplenic liquid collections, whose differential diagnosis was made between hematic collection and abscess. The treatment was splenectomy. The samples of collected liquid were positive for Escherichia Coli. Conclusion In case of splenic abscess, splenectomy is the best therapeutic choice. The other therapeutical options like antibiotic therapy and PCD, can be used only in particular cases, but without the same efficacy.

Highlights • Role of splenectomy in MF. • Kept in mind possible presence of peritoneal implants of extramedullary hematopoiesis. • Pathogenesis of ascites formation in MF., Introduction Primary myelofibrosis (MF) is a myeloproliferative neoplasm that results in debilitating constitutional symptoms, splenomegaly, and cytopenias. In patients with symptomatic splenomegaly, splenectomy remains a viable treatment option for MF patients with medically refractory symptomatic splenomegaly that precludes the use of ruxolitinib. Case presentation We present the clinical case of a patient who was admitted to our Department to perform a splenectomy in MF as a therapeutic step prior to an allogeneic stem cell transplantation (ASCT). A laparotomic splenectomy and excision of whitish wide-spread peritoneal and omental nodulations was performed. There were no operative complications and the surgery was completed with minimal blood loss. The histopathological exam revealed an extramedullary hematopoiesis in both spleen and peritoneal nodules. Conclusion In primary myelofibrosis it must always be kept in mind the possible presence of peritoneal implants of extramedullary hematopoiesis and ascites of reactive genesis. We report a rare case of peritoneal carcinomatosis-like implants of extramedullary hematopoiesis found at splenectomy for MF.

The objective of the present study was to assess safety, effectiveness, and long-term outcomes of stapled transanal rectal resection (STARR) for the cure of outlet obstruction syndrome (OOS). Data were collected over a 3-year period (2004–2007), at the Department of Surgery of the University of Genoa, from 25 consecutive subjects (19 of them females) undergoing STARR because of OOS that had not responded to medical treatment,. Preoperatively, patients were submitted to clinical examination, defecography, colonoscopy, manometry, and recto-anal reflexes determination. All patients had mucosal prolapse, 15 rectal intussusception, 15 rectocele. Postoperatively no deaths were observed; one patient had a hemorrhage requiring reintervention. Mean time to resumption of normal activity was 8.5 ± 4.5 days. Patients were followed for a mean of 24.7 ± 10.9 months (range: 6–42 months). Late specific complications included 3 cases of urge to defecate, 8 of incontinence to flatus. Functional outcome was positive for 22 patients (excellent in 4 cases, good in 15, fairly good in 3). Six months postoperatively (25 s), patients had improvement of the mean Constipation Score (p = 0.0002), less pain during evacuation (p = 0.0003), and reduced use of digital assistance to defecate (p

Background. Surgical attempts to treat obsity began because of the discouraging results of conservative medical treatment, which successfully achieved initial weight loss but failed to maintain it. Gastric restrictive procedures, currently the most popular surgical methods for obesity therapy, have proved to be effective in initiating weight loss, but some concerns regarding their long-term efficacy in weight maintenance have arisen. Methods. Of a total of 1968 obese patients who underwent biliopancreatic diversion since 1976, the last consecutive 1217 underwent the “ad hoc stomach” type of diversion with a 200 cm alimentary limb, a 50 cm common limb, and a gastric volume varying between 200 and 500 ml. Mean age was 37 years old (11 to 69 years), and mean excess weight was 117%. Maximum follow-up was 115 months with nearly 100% participation. Results. In the last half of the series, operative mortality was 0.4% with no general complications and with early surgical complications of wound dehiscence and infection (total, 1.2%) and late complications of incisional hernia (8.7%) and intestinal obstruction (1.2%). Mean percent loss of initial excess weight (IEW) at 2, 4, 6, and 8 years was 78±16, 75±16, 78±18, and 77±16 in the patients with IEW up to 120% and 74±12, 73±13, 73±12, and 72±10 in those with IEW more than 120%. A group of 40 patients who underwent the original “half-half” biliopancreatic diversion maintained a mean 70% reduction of IEW during a 15-year follow-up period. Specific late complications included anemia (less than 5%), stomal ulcer (2.8%), protein malnutrition (7% with 1.7% requiring surgical revision by common limb elongation or by restoration). Clinical problems from bone demineralization were minimal in the short term and almost absent in the long term. Conclusions. Biliopancreatic diversion is a very effective procedure but is potentially dangerous if used incorrectly.

Aim The SECCA system is a treatment option for patients with faecal incontinence and was introduced into clinical practice in 2002. Clinical studies of radiofrequency energy to treat patients with faecal incontinence have been published. This article aimed to review all published series to assess the results of this treatment. Method Twelve studies were included. Outcomes analysed included quality of life, the Wexner incontinence score, anorectal manometry and endoanal ultrasound findings. Results A total of 220 patients from 10 studies were included. In the majority of clinical studies, the SECCA procedure has been shown to be an effective treatment of mild-to-moderate faecal incontinence. Conclusion When patient selection is appropriate, this treatment has demonstrated clinically significant improvements in symptoms, as demonstrated by statistically significant reductions in the Wexner incontinence and quality of life scores.

Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with an increased death risk from cardiovascular diseases. However, while even minor renal dysfunction is an independent predictor of adverse cardiovascular prognosis, PEW becomes clinically manifest at an advanced stage, early before or during the dialytic stage. Mechanisms causing loss of muscle protein and fat are complex and not always associated with anorexia, but are linked to several abnormalities that stimulate protein degradation and/or decrease protein synthesis. In addition, data from experimental CKD indicate that uremia specifically blunts the regenerative potential in skeletal muscle, by acting on muscle stem cells. In this discussion recent findings regarding the mechanisms responsible for malnutrition and the increase in cardiovascular risk in CKD patients are discussed. During the course of CKD, the loss of kidney excretory and metabolic functions proceed together with the activation of pathways of endothelial damage, inflammation, acidosis, alterations in insulin signaling and anorexia which are likely to orchestrate net protein catabolism and the PEW syndrome.

Apoptosis and myostatin are major mediators of muscle atrophy and might therefore be involved in the wasting of uremia. To examine whether they are expressed in the skeletal muscle of patients with chronic kidney disease (CKD), we measured muscle apoptosis and myostatin mRNA and their related intracellular signal pathways in rectus abdominis biopsies obtained from 22 consecutive patients with stage 5 CKD scheduled for peritoneal dialysis. Apoptotic loss of myonuclei, determined by anti-single-stranded DNA antibody and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assays, was significantly increased three to fivefold, respectively. Additionally, myostatin and interleukin (IL)-6 gene expressions were significantly upregulated, whereas insulin-like growth factor-I mRNA was significantly lower than in controls. Phosphorylated JNK (c-Jun amino-terminal kinase) and its downstream effector, phospho-c-Jun, were significantly upregulated, whereas phospho-Akt was markedly downregulated. Multivariate analysis models showed that phospho-Akt and IL-6 contributed individually and significantly to the prediction of apoptosis and myostatin gene expression, respectively. Thus, our study found activation of multiple pathways that promote muscle atrophy in the skeletal muscle of patients with CKD. These pathways appear to be associated with different intracellular signals, and are likely differently regulated in patients with CKD.

Energy deficit is a common and serious problem in major surgical patients and is associated with increased rates of complications, length of stay, and mortality. Parental nutrition (PN), either alone or in combination with enteral nutrition, can improve nutrient delivery to this kind of patients. Lipids provide a key source of calories within PN formulations, preventing or correcting energy deficits and improving outcomes. In this article, we review the role of parenteral lipid emulsions (LEs) in the management of patients undergone to major surgical procedures and highlight important biologic activities associated with lipids. Soybean-oil-based LEs with high contents of polyunsaturated fatty acids (PUFA) were the first widely used formulations in the surgical setting. More recently developed parenteral LEs employ partial subsostitution of soybean oil with oils providing medium-chain triglycerides, omega-9 monounsaturated fatty acids or omega-3 PUFA. Manyof these LEs have demostrated reduced effects on oxidative stress, immune responses, and inflammation. Ongoing research using adequately designed and well-controlled studies that characterize the biological properties of LEs should assist clinicians in selecting LEs within the surgical setting.

Purpose To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures. Methods Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol/Tisseel) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12 months. Pain intensity was assessed by a visual analog scale VAS; 0 [no pain] to 10 [worst pain]). Results One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P = 0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P = 0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P

The patients with Crohn's disease (CD) have a greater risk of gastrointestinal and hemopoietic cancers compared with background population. Identify groups of people affected by CD with exposition to factors that play a role in the development of cancer could be useful to plan correct diagnostic and therapeutic methods.A reaserch on "pubmed" with "Risk factors for cancer in patients with Crohn's disease", "Cancer and Crohn's disease" Crohn's disease and cancer risk" as key-words was conducted. We identified 35 studies and analized also references reported inside each single work.Patients with CD have a higher risk of colorectal cancer (CRC). The risk of colon cancer alone was found to be increased, with no significant increase in the risk of rectal cancer. Factors that play a role in the development of CRC are: diagnosis of CD before 25-years-old, duration of disease, severity of inflammation, habit to cigarette's smoke, a familial history of CRC and immunosuppressive therapies. The risk of small bowel cancer was found to be increased, even if overall risk remains low. Although the role of immunosuppressive therapies remain to clarify yet, patients with CD have a higher risk of development lymphoma compared with background population.Patients with CD are at high risk of large bowel, small bowel, extraintestinal and hemopoietic cancers. Selected patients with extensive colonic disease, which has been present from a young age, are at high risk of cancer and should be candidates for colonscopic surveillance.

Crohn's disease is associated with high rates of postoperative recurrence. By 10 years postoperatively a high percentage of patients suffer clinical relapses (as many as 75% and above) and many of these (up to 45%) require re-intervention. The aim of the study was to identify, among the various potentially predictive factors, those which today can be considered real risk factors for postoperative recurrence. A review of the literature of the last two decades was carried out. Factors related to the patient, disease, type of surgery and pharmacological treatment were analysed. The relapse rate we recorded was 41.17% (28 of 62 patients operated on in the last 20 years and included in an average 6-year follow-up (range: 1-19 years). Significant predictive factors, in adition to duration of the follow-up and smoking, are also the location of the disease in the colon, extent more than 100 cm and the absence of postoperative pharmacological prophylaxis. The high incidence of postoperative recurrence in Crohn's disease mandates a strict follow-up (clinical, laboratory and instrumental monitoring). Identifying patients at increased risk would enable physicians to implement a rational pharmacological prophylaxis.

Removal of the submandibular and sublingual glands requires in-depth knowledge of the anatomy and scrupulous technique for the purposes of limiting the functional and aesthetic damage, which is unjustifiable above all in the treatment of benign lesions (sialodenitis, lithiasis). After presenting the main aspects of the surgical anatomy of the submandibular space, the operative technique for its dissection with removal of the submandibular gland and excision of the sublingual gland is described. The complexity of the anatomical structures that may be involved in submandibular and sublingual gland lesions is the cause of unsatisfactory functional and aesthetic outcomes in some cases. The most feared complications are lesions to nerve formations, due both to the resulting deficits and the possible legal implications.

A 10-year experience of abdominal wall hernia repair performed with anterior tension-free mesh or plug technique under local anesthesia in end-stage renal failure patients submitted to continuous ambulatory peritoneal dialysis (CAPD) is described in order to assess the safety and effectiveness of this approach.Between January 1993 and December 2002, 18 hernia repairs were performed under local anesthesia in 16 patients (14 males and two females) with a mean age of 70 years (48-78). One umbilical and three unilateral inguinal hernias were observed and repaired before starting peritoneal dialysis (PD), while two umbilical, eight unilateral, and two bilateral groin hernias developed and were then treated during PD. Repairs were performed electively in all but one case, which was an emergency operation for strangulation. An ipsilateral scrotal swelling was also present in two indirect unilateral inguinal hernias. In these cases, the hernia sac was ligated before entering, while in the others it was simply dissected and inverted.Patients were discharged the same day or the day after surgery. No local or general immediate or late complications occurred. CAPD in subjects operated on during PD treatment was resumed the same day of surgery. In no instance was hernia recurrence or leak of dialysis solution observed at follow-up examinations.The absence of surgical and general complications and the nearly immediate resumption of PD indicate the anterior tension-free repair under local anesthesia as a safe and effective technique for CAPD patients even in an ambulatory or day-surgery setting.

Background: Despite its simplicity, safety and good short-term results, progressive weight regain and a high incidence of complications have been reported after the adjustable silicone gastric banding (ASGB). The aim of this study is to evaluate the long-term results of this operation in our patient population. Methods: Between 1990 and 1996, 45 morbidly obese patients underwent insertion of an ASGB. The trend of the patients' BMI over time was studied using a linear mixed effect model adjusted for the preoperative BMI. So as to estimate the cumulative probability of band removal and the cumulative hazard function, Λ(t) Kaplan-Meier analysis was used. Results: 1 year after the operation, the average BMI was 79% of its preoperative value, which then increased linearly over time. The slope of the regression line was estimated at β =0.42, indicating an average increase of 0.42 BMI units per year. 27 bands (60%) were removed because of specific late complications. The cumulative risk of band removal increased linearly with time. The hazard rate was estimated to be λ =0.008 events/patient/month, corresponding to 0.1 events/patient/year. Conclusions: ASGB yielded good short-term results, but the progressive weight regain and constant risk of complications in the long term tend to nullify the optimism.

The aim of this study was to analyse radiological findings in patients surgically treated for adjustable silicone gastric banding (ASGB) for morbid obesity complicated by band penetration into the gastric lumen. We reviewed the records of four patients with surgically confirmed penetration of gastric band into the gastric lumen; three had preoperative opaque meal, one only a plain abdominal film. Vomiting was the presenting symptom in two cases, whereas others had new weight gain and loss of early satiety. Two patients had normally closed bands: radiography showed that their position had changed from previous controls and the barium meal had passed out of their lumen. Two patients had an open band. One patient had the band at the duodeno-jejunal junction, and the tube connecting the band to the subcutaneous port presented a winding course suggesting the duodenum. In the other case, both plain film and barium studies failed to demonstrate with certainty the intragastric position of the band. As ASGB is becoming widely used, radiologists need to be familiar with its appearances and its complications. Band penetration into the stomach is a serious complication which needs band removal. Patients with this problem, often with non-specific symptoms and even those who are asymptomatic, are encountered during radiographic examinations requested either for gastric problems or follow-up purposes, and have to be properly diagnosed.

To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment.One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations.Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred.Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.

Biliopancreatic diversion (BPD) has made reacceptable the malabsorptive approach to the surgical treatment of obesity. The procedure, in a series of 2241 patients operated on during a 21-year period, caused a mean permanent reduction of about 75% of the initial excess weight. The indefinite weight maintenance appears to be due to the existence of a threshold absorption capacity for fat and starch, and thus energy, and the weight loss is partly due to increased resting energy expenditure. Beneficial effects other than those consequent to weight loss or reduced nutrient absorption included permanent normalization of serum glucose and cholesterol without any medication and on totally free diet in 100% of cases, both phenomena being due to a specific action of the operation. Operative mortality was less than 0.5%. Specific late complications included anemia, less than 5% with adequate iron or folate supplementation (or both); stomal ulcer, reduced to 3.2% by oral H2-blocker prophylaxis; bone demineralization, increasing up to the fourth year and tending to decrease thereafter, with need of calcium and vitamin D supplementation; neurologic complications, totally avoidable by prompt vitamin B administration to patients at risk; protein malnutrition, which was reduced to a minimum of 3% with 1.3% recurrence, in exchange with a smaller weight loss, by adapting the volume of the gastric remnant and the length of the alimentary limb to the patient's individual characteristics. It is concluded that the correct use of BPD, based on the knowledge of its mechanisms of action, can make the procedure an effective, safe one in all hands.

Background This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. Methods From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66–93) years). Concomitant diseases were present in 157 patients, A mesh repair was performed with ‘tension-free’ or ‘plug’ techniques in all but 23 inguinal and two femora! hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. Results There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotl haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. Conclusion Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.

BACKGROUND AND METHODS: The relationships between cognitive restraint and the tendency to disinhibition, as assessed by the Three Factor Eating Questionnaire (TFEQ), and the weight loss at 1 year following gastric banding are evaluated. RESULTS: A significant predictability of the TFEQ Disinhibition score on the postoperative weight reduction was observed, while the amount of weight lost was negatively related to the preoperative TFEQ Cognitive Restraint score. CONCLUSION: It must then be hypothesized that the operated subjects feel a strong aversive stimulus and then they are led to reduce their food consumption only when they lose control and tend to overeat. The discomfort due to proximal gastric pouch distention facilitates the development of food aversion and then both the decrease of food intake and a change in eating behavior. The subjects must therefore be encouraged to adopt an eating style that cannot allow them to avoid such a feeling.

Wernicke-Korsakoff disease with sensory-motor neuropathy was diagnosed in three out of a series of 1,663 patients (0.18%), with onset 2, 3 and 5 months after biliopancreatic diversion. Precipitating factors were vomiting, minimal food intake, anorexia, rapid weight loss, and glucose-containing intravenous feeding. Recovery was partial in two and complete in one of the patients. In the early postop, prophylactic thiamine should be given to the patients with excessively limited eating capacity. Larger doses of thiamine should be instituted parenterally either in the case of suspected Wernicke-Korsakoff encephalopathy or before starting feeding for protein malnutrition.

Bone histomorphometry and vitamin D status were investigated in 41 patients studied 1–5 yr after partial or total biliopancreatic bypass. Metabolic bone disease, characterized by defective mineralization, decreased bone formation rate, and increased surface extent of resorption, was present in 30 patients (73%). Nine patients (22%) were hypocalcemic, but serum 25-hydroxyvitamin D concentrations were normal in all 41 patients. We conclude that metabolic bone disease is common after biliopancreatic bypass and usually occurs in the absence of simple vitamin D deficiency. The pathogenesis of the bone disease is unclear.

Summary Bilio-pancreatic bypass is a new procedure that tries to obtain a maldigestion syndrome with selective malabsorption of the main high calorie foods. The operation consists of a gastric resection and division of the proximal jejunum just distal to the ligament of Treitz. A gastroentero-anastomosis is then constructed using the distal end of the transected jejunum, while the proximal jejunum is anastomosed to the side of the distal ileum. An experimental study carried out on 12 dogs confirmed that the operation causes a selective malabsorption with loss of weight and no complications. On the basis of this study it is suggested that this procedure has the following advantages over jejuno-ileal bypass: (a) normal absorption of bile salts, water and electrolytes; (b) slow recovery of absorption; (c) absence of a blind loop.

The nutritional status prior to and 3 months and 1 year after biliopancreatic bypass surgery was evaluated. The common nutritional indexes (serum albumin and transferin concentrations, daily urinary creatinine excretion and delayed hypersensitivity) were determined. The body compartments were derived from total body water (TBW) and total body sodium (TBNa), measured by dilutional technique, and total body potassium (TBK), calculated from TBW, TBNa, and the ratio of the sodium plus potassium content divided by the water content in a sample of whole blood. Before surgery, obese patients showed a dilatation of both fat an lean compartments with a normal lean body mass (LBM) qualitative composition, as indicated by TBNa/TBW, and TBNa/TBK ratios not greater than those measured in controls. Three months following very-little-stomach biliopancreatic bypass (VLS BPB), a consistent reduction of body weight and body fat were observed. The body cell mass value fell and reached a level closely similar to that found in lean control subjects. LBM showed only a slight decrease. A sharp increase of TBNa/TBW and TBNa/TBK ratios demonstrated a dilatation of the extracellular space. This malnutritional status was not detected by the usual nutritional parameters. One year after VLS BPB surgery, the patients' body composition became very similar to that of lean subjects, though a TBNa greater than that of controls suggested that a slightly expanded extracellular space was still present.

Summary After a successful trial of bilio-pancreatic bypass in dogs, a clinical study has been completed in 18 patients followed for more than 1 year. The operation has been modified to achieve the best weight reduction, and forming the bilio-pancreatic tract of equal length to the alimentary tract with a short common ileal tract, the average weight loss as a percentage of the preoperative body weight was 24·1 ± 5·4 per cent (mean ± s.d.) at 6 months and 33·7 ± 4·1 per cent at 12 months. The only immediate complication was a wound dehiscence, and there were no late complications. Liver function studies showed the absence of hepatic deterioration and liver biopsies showed improvement of liver morphology 1 year after the operation. It is suggested that this procedure may be an alternative to jejuno-ileal bypass in the management of obesity.

Biliopancreatic diversion is a very effective method for weight reduction. In some instances it is too effective and needs to be revised.

One hundred and seventy-seven end-to-end arteriovenous fistulas were created at the ‘anatomical snuffbox’ between 1 January 1972 and 31 December 1980. The survival rate of the fistulas was 83·1 per cent at 1 year and 46·3 per cent at 6·5 years; 10·2 per cent failed immediately. Local and general complications were virtually absent. Forty fistulas stopped functioning after a period varying from 10 days to 6·5 years following the operation. The main cause of late failure (50 per cent) was aneurysm formation due to repeated needle venepuncture at the same site and subsequent obliteration of the upper venous segment. The end-to-end anastomosis seems to be preferable to other techniques because of the absence of local vascular complications and a lower risk of cardiac embarassment. The ‘anatomical snuffbox’ site is convenient and spares the proximal vessels for reoperation if necessary.

Protein malnutrition is the main early problem with biliopancreatic diversion; gastric volume greatly influences the incidence of protein malnutrition.

When paired data are considered and unpaired results are compared with controls, it appears that no significant changes of gastric histomorphology occur following biliopancreatic diversion.

Pancreatic secretions have been shown to be important in zinc absorption in experimental animals. Recently, complete surgical diversion of biliary and pancreatic secretions from the functioning small intestine has been utilized in Europe to treat morbid obesity. To determine the importance of pancreatic secretions in zinc absorption in the human, we measured hair and serum zinc levels in 14 patients having undergone complete biliopancreatic bypass 12–56 months earlier and compared these values with those obtained from 11 patients subjected to only partial biliopancreatic bypass as well as to six morbidly obese controls. No differences were observed in either hair or serum zinc levels between any of these groups of patients. Pancreatic secretions do not appear to be necessary for adequate zinc absorption in humans.