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We present a case report of hepatic resection performed laparoscopically for a giant symptomatic hemangioma. The patient was a 50-year-old woman who was diagnosed with a giant hemangioma 20 cm in diameter. As in the case of our patient, laparoscopic resection of hepatic hemangiomas can be performed successfully, even when dealing with giant hemangiomas. However, a thorough preoperative assessment and a structured approach, in our case including preoperative embolization, is crucial for success.

Background: Laparoscopic adjustable gastric banding is effective in inducing weight loss, as well as being minimally invasive, totally reversible, and adjustable to the patient's needs. The aim of this study was to assess the efficacy and safety of adjustable gastric banding with the Swedish band (SAGB) in super-obese patients., Patients and Methods: Between January 1996 and December 2003, 682 patients (570 women, 112 men) underwent SABG implantation. In these patients, there were 60 super-obese patients with a BMI >/= 50 kg/m(2). Two groups of patients were analyzed: Group 50 (n = 30 patients) with a BMI 50-54 kg/m(2) and Group 55 (n = 30 patients) with a BMI >/= 55 kg/m(2). 13 different surgeons (9 general and 4 bariatric surgeons) performed the SAGB. All data (demographic and morphologic data, operative data, and follow-up data) were prospectively collected in a computerized data bank., Results: 60 patients (8.8%) out of 682 were super-obese and entered the study. Mean %EWL was 39.2 at 1 year and 60.4 at 4 years, BMI fell from 55.5 to 34.7 at 4 years. The complication rate was 26.7% (16/60). General surgeons 12/60 (20%) had more complications than bariatric surgeons 4/60 (6.7%). In Group 50, mean %EWL was 42.1 at 1 year, 55.9 at 2 years, 61.5 at 3 years and 59.9 at 4 years. BMI fell from 51.8 to 33.2 at 4 years. Postoperative complications occurred in 6/30 patients (20%): pouch dilatation (n=2), band migration (n=2) and band leakage (n=2). In Group 55, mean %EWL was 36.8 at 1 year, 55.3 at 2 years, 55.8 at 3 years, and 59.4 at 4 years. BMI fell from 59.1 to 36.4 at 4 years. Postoperative complications occurred in 10/30 patients (33.3%): pouch dilatation (n=2), band migration (n=3) and band leakage (n=5). There was no mortality., Conclusion: SAGB is an effective procedure for the surgical treatment of super-obesity. Because of the high complication rate, super-obese patients should only be treated by experienced bariatric surgeons.

Background: Patients who are suspected of having acute appendicitis usually undergo surgery in order to avoid life-threatening complications such as perforation and peritonitis. However, acute appendicitis is difficult to distinguish from other sources of right-sided abdominal pain. The clinical picture is almost indistinguishable from appendiceal diverticulitis, which is a rare entity and remains a difficult diagnostic problem., Patients and Methods: We describe the case of a 39-year-old male with perforated appendiceal diverticulitis. The patient was admitted to our surgical unit with acute appendicitis-like symptoms and underwent surgery with a diagnosis of suspected acute appendicitis., Results: The patient was found to have perforated appendiceal diverticulitis and standard appendectomy with abdominal lavage was carried out., Discussion: Most patients presenting with acute right-sided peritonitic pain are diagnosed and managed as cases of acute appendicitis. Acute pain in the lower right side of the abdomen caused by appendiceal diverticulitis is very rare and clinically indistinguishable from acute appendicitis. Inflammatory complications of appendiceal diverticula mimic acute appendicitis., Conclusion: Every surgeon should be aware of the possibility of diverticulitis of the appendix in the operating room, even if this does not change the operative management. As diverticula of the cecum can be found as solitary lesions, as multiple lesions confined to the right colon, or as part of a generalized disease of the entire colon, postoperative barium enema examination may be useful.

Background: Laparoscopic adjustable gastric banding is effective in inducing weight loss, as well as being minimally invasive, totally reversible, and adjustable to the patient's needs. Nevertheless, leakage of the adjustable balloon is a known complication. The aim of this study was to assess the incidence and reasons for balloon leakage of the Swedish adjustable gastric band (SAGB)., Patients and Methods: Between January 1996 and December 2002, 566 patients (475 women, 91 men) underwent a laparoscopic SAGB implantation. Two groups of patients were analyzed: patients with early postoperative leakage (Group E) and patients with late postoperative leakage (Group L). All data (age, gender, pre- and postoperative weight, time of weight gain, band filling status) were prospectively collected in a computerized data bank. For the detection of gastric band leakage, radiography and the technetium-99m colloid scintigraphy was used., Results: 25 band leakages were observed in 22 patients (4.4%). All these patients had a silent presentation of band leakage, with weight regain and an ability to eat without major restriction. Band leakages in group E were detected during the band filling period after a median follow-up of 8 months and after 30.3 months (P <0.0001) in group L. In group E, all 13 leakages possibly resulted from inappropriate handling of the device during surgery. In 2 cases in group L, a tear of the balloon had occurred where it is fixed to the band. The other 10 bands showed breaks at the edges of the inner side of the balloon. All leakages could be detected by (99m)Tc colloid scintigraphy, whereas only 58% of the leakages could be detected by radiography., Conclusion: Band leakage is a rare complication and should be considered if a patient starts to regain weight. Operative failure as well as material defects may account for this complication. The balloon leakage can effectively be detected by (99m)Tc colloid-scintigraphy.

Background: Laparoscopic silicone adjustable gastric banding (SAGB) has gained popularity for the surgical treatment of morbid obesity. The implantable gastric stimulator (IGS) system represents a novel surgical alternative. We aimed to assess the feasibility of robotic-assisted laparoscopic bariatric operations and to critically elucidate the technical and financial advantages and patient outcome., Methods: Robotic-assisted laparoscopic bariatric procedures were performed on 10 consecutive patients using the daVinci robot system (4 SAGB, 4 IGS, 2 SAGB revisions). 10 conventional laparoscopic-operated patients (4 SAGB, 4 IGS, 2 SAGB revisions) during the learning curve served as controls. Equipment, operative technique and procedural time were evaluated. A cost analysis was calculated., Results: The personnel equipment, numbers of trocars and operation technique were comparable in both groups. The mean operative time was 137 min (range 110-175) and 97 min (60-140) in robotic-assisted and conventional laparoscopy, respectively (P =0.04). Establishment of the pneumoperitoneum and placement of trocars and robotic arms took a mean of 30 min (15-45) in the robotic-assisted group, compared with 5 min in the control group (P <0.001). In 1 patient, intraoperative gastric injury was suspected and led to band removal in the robotic-assisted group. There was no postoperative complication. Average procedural costs were significantly higher in the robotic-assisted group., Conclusion: Primary and revisional robotic-assisted bariatric surgery is technically simple, with the benefit of precise instrument handling. However, it is still expensive, the set-up of the system is time-consuming, and a limited variety of instruments are available presently.

Background: The advantages of laparoscopy over open surgery are well known. The aim of this study was to compare our results with Swedish adjustable gastric banding (SAGB) with other laparoscopically performed bariatric procedures (gastric bypass, LapBand, vertical banded gastroplasty)., Methods: Between January 1996 and December 2001, 454 patients (381 women, 73 men) underwent laparoscopic SAGB. All data (demographic and morphologic, co-morbidities, operative, and follow-up) were prospectively collected in a computerized databank., Results: Mean follow-up was 30 months (range 1-66). Average total weight loss was 35.5 kg after 1 year, reaching an average total of 54 kg after 3 years. Mean excess weight loss was 72% after 3 years, and the BMI decreased from 46.7 to 28.1 kg/m(2). Patients with co-morbidities reported marked improvement of their accompanying diseases. Complications requiring reoperation occurred in 7.9%. There was no mortality. The clinical outcome compared with the other laparoscopic bariatric procedures showed no significant difference., Conclusion: All laparoscopically performed bariatric procedures are very promising. The great advantage of laparoscopic adjustable gastric banding is that this operation is minimally invasive to the stomach, totally reversible and adjustable to the patients' needs.

From January 1996 to July 2001, 530 patients underwent a laparoscopic gastric banding operation at the University Hospital of Innsbruck. In one of these patients, a pneumomediastinum developed 17 months after surgery. Unable to swallow, the 28-year-old patient suddenly felt sick and reported left chest pain. Additionally, recurrent vomiting and later hematemesis were reported. A band migration was excluded via endoscopy. After the diagnosis of a mediastinalemphysema was established, the patient was treated conservatively. The causes of mediastinalemphysema are heterogeneous and sometimes not exactly clear. In our patient it is a question whether vomiting led to an esophageal tear, which in turn was responsible for the mediastinalemphysema.

Background: Laparoscopic adjustable gastric banding (LAGB) is an effective method in the treatment of morbid obesity. However, it is unknown, whether deflating the gastric band before operations under general anesthesia is necessary to avoid complications such as nausea, vomiting, respiratory complications, and weight regain., Methods: Between January 1996 and June 2001, we performed LAGB on 408 patients at the University Hospital of Innsbruck. Of these patients, we identified 68 (16.7%) patients who were to undergo subsequent unrelated general, reconstructive, vascular, or orthopedic procedures. These patients were prospectively randomized into two groups: group 1 (n = 32) preoperative deflation of the adjustable band system and group 2 (n = 36) without preoperative deflation of the adjustable band system., Results: There were no anesthetic or perioperative band-related complications in either group 1 or group 2. There were two reoperations necessary due to surgical complications unrelated to the gastric band., Conclusions: Operations after adjustable gastric banding can be safely performed without deflating the adjustable system.

Background: Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial., Materials and Methods: Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively., Results: Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies., Conclusions: Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.

Objective: Soluble leptin receptor (sOB-R) represents the main binding site for leptin in human blood. The aim of this study was to investigate the relationship between leptin and soluble leptin receptor and the bound/free ratio after pronounced weight reduction., Research Methods and Procedures: A total of 18 morbidly obese women participated in this prospective study. Subjects were examined for fat mass, leptin, and sOB-R concentrations before and 1 year after Swedish adjustable gastric banding., Results: Anthropomorphic measures displayed a significant reduction of body mass index [(42.9 +/- 5.6 to 32.9 +/- 6.0 kg/m(2) (mean +/- SD)]. Fat mass decreased from 56.3 +/- 9.0 to 33.9 +/- 12.5 kg. Plasma leptin concentration decreased from 44.6 +/- 18.0 to 20.0 +/- 13.1 ng/mL (p < 0.001), whereas the sOB-R levels increased from 11.1 +/- 3.6 to 16.6 +/- 6.0 U/mL after weight-reducing surgery. Thus, the sOB-R bound fraction of leptin increased from 7% to 33%., Discussion: This work demonstrates a relationship between weight loss, leptin, and sOB-R concentrations in vivo. During weight loss, leptin levels decreased, whereas sOB-R levels and the receptor bound fraction of leptin increased. Thus, sOB-R may negatively regulate free leptin.

Background: The aim of this study was to assess the incidence of intragastric migration of the Swedish adjustable gastric band (SAGB) and to evaluate the safety and effectiveness of gastroscopic band removal., Methods: Between January 1996 and December 2001, 454 patients (381 women, 73 men) underwent a laparoscopic SAGB operation. All data (age, gender, pre- and postoperative weight, time of weight gain, band filling status, endoscopic diagnosis of migration, total weight reduction) were prospectively collected in a computerized data bank., Results: Out of the 454 SAGB operations, 14 (3.1%) intragastric band migrations were observed. The average preoperative weight was 122.2 kg and the average postoperative minimum weight was 80.4 kg. All 14 patients had unexplained weight gain on an average of 20 months after the operation. The average band filling status was 8.2 ml. In 12 patients, the band was removed endoscopically, avoiding laparotomy. The remaining 2 patients are under endoscopic surveillance. The mean operating time was 120 minutes. No peri- or postoperative complication was observed., Conclusion: Intragastric band migration is a rare complication and should be considered if a patient starts to regain weight. Migration does not require immediate therapy and therefore this complication could be safely treated endoscopically.

Background: Early or late pouch dilatations account for a moderate complication rate after restrictive bariatric operations. Various strategies were developed to prevent or treat pouch dilatations., Methods: A case of necrosis of gastric wall in a concentric dilated pouch following laparoscopic adjustable gastric banding is reported as a severe complication of a conservative treatment attempt., Results: Emergency laparotomy resulted in band removal, partial gastric resection and prolonged hospital stay., Conclusion: Conservative strategies in the treatment of pouch dilatations bear the risk of complications, with both failure of the bariatric procedure and critical clinical course. Indication for early operative reintervention is recommended.

Hypothesis: Older patients experience the same benefits from a laparoscopic gastric banding (LGB) operation as younger patients., Design: A case series of 320 morbidly obese and superobese patients who underwent LGB within a 46-month period., Setting: University Hospital Innsbruck, General Surgical Department, Innsbruck, Austria., Patients: A consecutive sample of 320 patients who met the criteria for a bariatric procedure and were aged 18 years or older. Patients were divided into the following 2 age groups: younger patients (group A, 18-49 years) and older patients (group B, > or =50 years)., Intervention: Laparoscopic gastric banding with an adjustable gastric band., Main Outcome Measures: Clinicopathologic features, including weight loss, complications, length of hospital stay, and operative times, were reviewed retrospectively, and a multivariate analysis was carried out., Results: Of 320 patients, we identified 68 older patients (21.5%, group B). The mean postoperative follow-up period was 12 months (range, 6-28 months). The average preoperative weight was 127.8 kg (body mass index [calculated as weight in kilograms divided by the square of height in meters], 44.29). The average total weight loss was 4.3 kg per month for the first 3 months, reaching an average total of 31.0 kg after 1 year. The excess weight loss after 12 months was 68%. Complications requiring reoperation occurred in 10.3% of patients. Ninety-seven percent of the patients reported an improvement in their comorbid conditions., Conclusions: Older patients receive the same benefits from LGB as younger patients, with an acceptable postoperative complication rate. Presently, our upper age limit is 70 years.

Background: Adjustable gastric banding has become the preferred procedure in Europe for the treatment of morbid obesity. A complication of this treatment is the presence of leakage in the system. The knowledge of the localization of the leak is essential for planning the reoperation procedure., Patients and Methods: In a series of 325 adjustable gastric bandings, we observed 10 band leakages. In 3 cases, fluoroscopy failed to detect fluid extravasation. We present a sensitive and simple scintigraphic method for the detection of gastric band leakage in these patients using 37 MBq of a 99mTc-human albumin colloid suspension. Imaging was started immediately after the dose application. During the first minute, images were acquired dynamically with 1 frame every 2 seconds. Afterwards, a static image was obtained every 10 minutes, up to 60 minutes post-injection. Then the system was emptied completely to detect tracer extravasation and consecutive reabsorption during 60 minutes. The study was analyzed by using the regions of interest (ROI) technique drawn on the following points: injection reservoir, tube, anterior band, posterior band, and an adjacent region which was taken as background., Results: During the first hour, ROI analysis showed a clear diminution in the number of counts contained in the defect parts of the band, whereas it remained constant in the other locations. After system emptying, detection of tracer extravasation further strengthened the diagnosis of band leakage in all patients., Conclusion: This new approach using the 99mTc-human albumin colloid suspension with ROI analysis is an effective and simple method to detect occult leakages in adjustable gastric bands which escaped detection by fluoroscopy. In contrast to previously described scintigraphic methods, this investigation is able to demonstrate the exact site of leakage.

Background: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding., Methods: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery., Results: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation., Conclusions: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.

Background: Vertical banded gastroplasty (VBG) causes weight loss, which is often associated with redundant abdominal tissue. This redundant tissue can be used successfully for breast reconstruction or breast augmentation in case of mastectomy or ptotic hypotrophic breasts., Method: One patient with bilateral mastectomy is described in whom the weight fell from BMI 52 to BMI 26 after VBG, giving the patient an abdominal "apron", which facilitated bilateral breast reconstruction., Results: Bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction after weight reduction following VBG resulted in an esthetic pleasing result with additional correction of the cutis laxa abdominis., Conclusion: Autologous breast reconstruction can be performed safely with the methods used today, after successful weight loss following obesity surgery.

Acute liver failure due to intoxication is a rare indication for liver transplantation which a usually has a good prognosis. We herein report the case of a young male, who underwent orthotopic liver transplantation for acute liver failure due to carbon tetrachloride intoxication. Apart from hepatic and renal failure, the patient also developed severe rhabdomyolysis, which has not thus far been described as a toxic effect of this chemical agent. Despite forced hyperventilation, which is known to be the most effective means of eliminating the specifically lipophylic agent, as well as excessive plasma exchange following intravenous administration of fat emulsions, liver failure recurred when blood carbon tetrachloride concentrations were already at non-toxic levels. Retransplantation of the liver together with a kidney was only temporarily successful, since the patient died due to aspergillus sepsis. Based on this experience, we would recommend that whenever possible in patients with carbon tetrachloride intoxication, liver transplant should be delayed until most of the toxic agent has been eliminated in order to prevent fatal graft damage.