|
© Borgis - Postępy Nauk Medycznych 7, s. 545-550
*Mariusz Wyleżoł1, Krzysztof Paśnik2
Revisional bariatric surgery in patients who underwent surgical treatment for morbid obesity
Chirurgia rewizyjna u chorych poddanych leczeniu operacyjnemu otyłości olbrzymiej
1Department of Surgery, Military Institute of Aviation Medicine, Warsaw, Poland
Head of Department: Mariusz Wyleżoł, MD, PhD 2Department of General, Oncological and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland Head of Department: Krzysztof Pa?nik, MD, PhD Streszczenie
Revisional surgery may be necessary in some patients who have undergone bariatric operations. The paper presents causes, manifestations, diagnosis and treatment in patients requiring revisional surgery. The most common indications for reoperation include insufficient weight loss, weight regain, decrease in quality of life, and complications following the primary procedure. Insufficient weight loss and weight regain can be caused by staple line disruption in patients after gastroplasty. Band migration is a serious complication which can be present in any type of primary banded gastroplasty. Restriction can also disappear due to leakage of the system after adjustable gastric banding. Gastric pouch enlargement and dilatation of the stoma are responsible for restriction disappearance after malabsorptive procedures. Vomiting may be life-threatening when stenosis develops following gastroplasty, gastric bypass or due to band slippage. Marginal ulceration is usually treated conservatively nowadays, although it could also be an indication for surgery. Currently no randomized controlled trials exist to help the practising bariatric surgeon choose which revisional procedure to perform. The treatment strategy can be planned and discussed preoperatively with patients although the intraoperative situation frequently influences the type of the procedure performed. Intestinal obstruction and other pathologies and complications can sometimes be indications for emergency surgical procedures. Słowa kluczowe: surgery, obesity, bariatric surgery, revision, reoperation
Summary
Chirurgia rewizyjna może okazać się niezbędna u części chorych poddanych uprzednio operacjom z powodu otyłości patologicznej. Omówiono przyczyny, objawy, rozpoznanie i postępowanie u chorych wymagających operacji rewizyjnych. Najczęstszymi wskazaniami do kolejnych operacji są: niewystarczająca redukcja masy ciała lub jej ponowny wzrost, obniżenie jakości życia lub powikłania pierwotnej operacji. Niewystarczająca redukcja masy ciała i ponowny jej wzrost u chorych poddanych uprzednio gastroplastyce mogą być spowodowane rozerwaniem linii podziału żołądka. Migracja opaski jest poważnym powikłaniem, które może wystąpić po każdej operacji z jej zastosowaniem. Ustąpienie restrykcji u chorego z wszczepioną opaską regulowaną może być spowodowane nieszczelnością systemu. Powiększenie górnej części żołądka lub poszerzenia zespolenia żołądkowo-jelitowego jest odpowiedzialne za ustąpienie restrykcji po operacjach wyłączających. Wymioty mogą zagrażać życiu, gdy są wynikiem zwężenia żołądka bądź zsunięcia się opaski. Owrzodzenia brzeżne są obecnie leczone zachowawczo, niemniej mogą być także wskazaniem do leczenia operacyjnego. Niestety brak jest aktualnie wyników badań randomizowanych, które byłyby pomocne w podjęciu decyzji o rodzaju zabiegu rewizyjnego. Strategia postępowania może być zaplanowana i przedyskutowana z chorym w okresie przedoperacyjnym, aczkolwiek sytuacja śródoperacyjna może wpłynąć na rodzaj wykonanej operacji. Niedrożność jelitowa i inne patologie a także powikłania mogą być czasami wskazaniem do niezwłocznie wdrożonego leczenia operacyjnego. Key words: chirurgia, otyłość, chirurgiczne leczenie otyłości, rewizja, reoperacja
Since the number of morbidly obese people is increasing and the effectiveness of conservative treatment of the disease is not improving, increasing numbers of patients undergo surgery. This refers to many countries worldwide, including Poland (1). Moreover, surgery procedures whose origin is obesity treatment are more and more commonly used in treating diabetes, lipid disorders and others, regardless of the body mass index (BMI) (2, 3). This means that an increasing number of health professionals, both surgeons and other specialists, can in their practice encounter patients who have undergone such surgical treatment. In some cases, an urgent intervention, possibly surgical, may be mandatory to save a patient´s life. In such situations, there will be no time to refer the patient to a centre that specializes in surgical obesity treatment.
This obliges physicians, and particularly surgeons, to become familiar with possible complications encountered in people who have undergone surgical obesity treatment so that they will be able to diagnose a patient or refer a patient to an appropriate centre. What is important is the fact that a patient who has undergone bariatric surgery, like after any other surgery, can develop any morbidity known to medicine, not necessarily related to the surgical treatment. Treating such morbidities may require an awareness of the changes in the anatomy of the gastrointestinal tract which result from the surgical treatment.
There is now scientific evidence which proves unambiguously that conservative treatment is ineffective in morbid obesity. The same evidence indicates that surgical methods exert a beneficial effect on all health aspects associated with this disease. Yet, still there can be opinions heard which question the rationale of surgery in obesity. One of the most important arguments is the opinion that many patients have to be reoperated because they have developed weight regain and other complications that require surgical intervention. In this context, a question arises: ´Does anyone question the use of surgery in other diseases if the necessity of reoperation appears?´ This refers both to systemic diseases, e.g. critical lower extremity ischaemia (CLEI) of atherosclerotic genesis, or local morbidities, e.g. hernia recurrence, to say nothing of neoplastic diseases. Thus, a characteristic feature of surgery is that so far an ideal, complication-free method of surgical obesity treatment is lacking and one will (probably) not appear as long as our treatment does not become causal. A similar situation existed twenty or thirty years ago in the case of peptic ulcer disease.
Revisional surgery for obesity has been known and performed since the first surgery to treat obesity was used. It was limited to intestinal bypass procedures (4, 5). The methods which were suggested then were converting intestinal bypass into gastric bypass or simultaneous reconstruction of the alimentary tract continuity and gastroplasty (6, 7, 8). The following years brought publications describing revisional surgery, during which gastric bypass was converted into vertical banded gastroplasty (9). This type of procedure resulted in body mass loss combined with metabolic disorder avoidance. In patients after primary gastroplasty, the most common cause of reoperation was a breakdown of the staple line, dilation of the canal between the stomach parts created by gastroplasty, or enlargement of the upper part of the stomach. Such phenomena made surgeons convert gastroplasty into gastric bypass (10).
Over the years, the definitions of revisional surgery have changed. In the 1980s, Linner suggested that a reoperation which was to prevent weight regain in patients who had undergone surgical obesity treatment should be named revisional surgery. This term also referred to procedures which counteracted or prevented complications related to obesity treatment surgery (11). At present, medical English differentiates reoperation (surgical interventions associated with complications) and revisions (surgery whose task is further treatment of obesity). Of note, over the years revisional surgery has gained such a status in obesity treatment that multistage surgical obesity treatment is spoken of more and more often. Shortening the duration of each stage contributes to decreasing the number of peri- and post-operative complications. An example of multi-stage treatment is gastric sleeve resection as the first stage followed by gastric bypass or duodenal switch. Gastric banding followed by duodenal switch can be another example of morbid obesity treated in a multi-stage way (12). There may be many more examples of such multi-stage therapy practised today.
Considering the practical aspects of contemporary revisional surgery for obesity treatment, the following three possibilities should be kept in mind (13):
– Insufficient weight loss or weight regain;
– Complications deteriorating the quality of life but not threatening life;
– Life-threatening complications.
When a patient is qualified for reoperation due to insufficient weight loss, it must be remembered that there are still no objective criteria to decide which body mass loss reduction rate should be considered desirable. There have been attempts to design a scoring system, but none has been accepted universally. That is why the weight reduction is based on the patient´s self-assessment and is very subjective. The role of a physician is to make a complex evaluation of a patient´s general condition by assessing: the degree of weight loss, nutritional status (including possible deficiency syndromes), co-morbidities (especially those present before surgery), and quality of life. Thus qualifying a patient for reoperation due to "insufficient reduction of body mass” should be very cautious and include the risk related to undergoing another surgical procedure.
The situation when a patient´s body mass has increased again is somewhat different. In such cases, a patient needs to undergo thorough diagnostic examinations and tests, including imaging diagnostics, so that the cause can be found. Depending on the pathology found, a patient should be treated in a way which can protect him/her against further weight gain, which will soon result in a relapse of the obesity-accompanying diseases diagnosed before the primary surgery. When such patients are qualified for revisional surgery, the referential body mass must be the maximal body mass the patient has ever attained in the lifetime and not the present mass, which may be smaller.
A completely different phenomenon is „bariatric cachexia”. Depending on the type of the primary procedure, bariatric cachexia can have different forms. Caloric deficiency is usually observed in patients treated with restrictive procedures. In patients treated with bypass procedures, different forms of protein deficiency can develop. Deficiency of other nutrients may or may not accompany them. Bariatric cachexia affects rather few patients, but the condition is so life-threatening that it needs health professionals´ urgent intervention. When conservative treatment fails, surgery is necessary.
Indications for reoperation may be shared by all types of surgical obesity treatment. Yet in many cases, a physician´s decisions will depend on the type of primary surgery and pathologies present.
In the case of vertical banded gastroplasty, the most common indication for reoperation is breakdown of the gastric staple line. It manifests with abrupt or gradual restriction release and body mass gain due to formation of an additional canal through which food can penetrate the other part of the stomach. Radiography of the upper part of the gastrointestinal tract is essential for the diagnosis (fig. 1).
 Fig. 1. Radiogram of staple line breakdown across stomach.
Endoscopically, it is sometimes possible to confirm the existence of an additional discontinuity in the staple line across the stomach. At present, laparoscopic gastroplasty patients have their stomach dissected in the staple line. This limits the likelihood of formation of another canal but does not exclude it (14).
The restriction can become smaller also because the band has migrated into the gastric lumen. The migration is sometimes preceded by atypical epigastric pains. Radiogram reveals lack of the characteristic narrowing of the canal connecting the upper and lower parts of the stomach. Endoscopy confirms the presence of a foreign body in the gastric lumen (fig. 2).
 Fig. 2. Band fragment in gastric lumen.
Band migration can be accompanied by breakdown of the staple line.
When breakdown of the staple line occurs, vertical banded gastroplasty is converted into gastric bypass. Frequently, the procedure has to include resection of a further fragment of the stomach. This is necessary when the band has migrated or a gastro-gastric fistula has formed in the staple line. Severe lesions around such a foreign body as a band require the lower part of the stomach to be resected. Choosing the bypass option results from the experience of many authors, who reported that the reconstruction of the anatomical conditions characteristic of gastroplasty did not result in a permanent outcome (15). Some patients, who tolerated the previous restriction well, and did not complain of epigastric pains, pyrosis or inflammatory states, can undergo reconstructive gastroplasty. When the band migration is not accompanied by other complications, an attempt can be made to remove it endoscopically (16). Such treatment facilitates performing another bariatric operation in the future, but also postpones it and contributes to further and uncontrolled weight gains. When the band cannot be removed endoscopically, it has to be removed surgically. The procedure will typically lead to simultaneously performing another procedure, i.e. gastric bypass.
Patients who have undergone vertical banded gastroplasty can also develop gastric canal narrowing at the level of the band applied. It is caused by concentric tissue adhesions around the band. The result is upper gastrectasia and occlusion causing persistent vomiting, which can lead to exhaustion, dehydration and severe electrolyte disturbances. Some patients can benefit from endoscopic dilatation of the canal. In many cases, surgical intervention is necessary; its type depends on the complex assessment of a patient´s preoperative condition and the intraoperative situation. The adhesions can be released and the band can be replaced, which can restore the normal patency between both parts of the stomach. Some patients can benefit from gastric bypass creation.
Gastric banding is the most common procedure in Europe. It is gaining popularity in the US too. The restriction degree is adjustable. To attain this, a valve (port), which is connected to the band with a drain, is placed subcutaneously. Placing the port under the skin can lead to infection. The band, port and drain make up a closed system; it can lose its tightness and stop being restrictive. The problem can be solved by port replacement, drain shortening or band replacement. The necessity to reoperate may result from the method applied and from the equipment used during surgery.
The band can migrate when the upper part of the stomach becomes too big because the system has been overfilled with a large amount of food or the canal has become too tight. This leads to occlusion of the upper alimentary tract, which is manifested by persistent vomiting and inability to take liquid food. Upper gastrointestinal tract radiograms reveal severe dilatation of the stomach upper part and sometimes oesophagus with a concomitant change in the band positioning angle (fig. 3).
 Fig. 3. Radiogram of a female patient with the upper part of the stomach leaning over the band.
The interrelation between the upper stomach part and the band turns into an internal hernia, which can lead to gastric incarceration, and consequently to its strangulation and necrosis. Such cases have been described in the literature (17). That is why permanent vomiting in banded gastroplasty patients should be treated very seriously. Emergency treatment, depending on the severity of manifestations, includes partial or total emptying of the system. Such treatment is sufficient in some patients. Yet if the gastric canal occlusion and the upper stomach enlargement persist, a surgical intervention is necessary. During reoperation, the band is moved proximally and the subcardial part of the stomach is reduced. In some patients, it is recommended to remove the band and perform another simultaneous or delayed operation, e.g. gastric bypass or biliopancreatic diversion.
When the restriction is loosened in a patient with an adjustable band, the result is either the band´s migration into the gastric lumen or leakage resulting from lack of system tightness. Migration creates an additional canal around the band. Through this canal, food can easily move to the other part of the stomach. When the band migrates into the gastric lumen, radiograms show how contrast medium flows beyond the band constricting the stomach (fig. 4).
 Fig. 4. Radiogram of a female patient with band migration into gastric lumen.
In some cases, it is necessary to fill up the system so that the band clearance can be closed. Endoscopy usually confirms that there is a cord-like foreign body in the upper stomach. It must be absolutely clear that migration means there is communication between the alimentary tract lumen and the peritoneal cavity. Such a communication opening or such openings are usually tightly covered with surrounding tissue, which prevents diffuse peritonitis from developing. However, there have been cases where infection within the peritoneal cavity was described (18). Thus, each case of migration should be treated very seriously. The band can be removed endoscopically or surgically. Some researchers reported the safety of a simultaneous procedure during surgical band removal – typically gastric bypass (19). A two-stage approach seems safer, though. In the second stage after six months, another operation is performed. Both band replacing and gastric bypass have been reported. In some patients, repeated band migration is described. On the other hand, it is difficult to foresee the degree of weight loss after gastric bypass procedures, and sometimes it may be insufficient.
In patients in whom band migration has been excluded, lack of restriction can result from lack of system tightness. Most often, the site of leakage is where the drain connects with the valve or the band, or valve membrane damage caused by the use of inappropriate needles during filling or emptying the system. Radiography, during which contrast medium is applied into the band system, usually reveals where the system is no longer tight and helps to decide about further treatment. Then part of the system can be replaced. Unfortunately, in some patients micro-leakage cannot be confirmed radiologically. A characteristic feature then is a gradual restriction yielding a few days after the system was filled. In such cases, the whole system has to be replaced.
The above-described indications for reoperating on patients who have previously undergone either gastric bypass or banding surgery are related to pathologies, which can be discovered if the diagnostics is performed appropriately. In the case of restrictive surgery, imaging studies may not reveal pathology although patients complain of restriction intolerance or their weight loss is insufficient or they even develop weight gain. This fact may result from wrong dietary habits or eating high-calorie, half-solid or liquid meals. In both situations, consultation with a dietician or psychologist may help. In some patients, though, there are indications for another bariatric surgical procedure. The best solution then is bypass surgery.
In recent years, sleeve gastrectomy has gained increasing popularity. There are no results of long-term studies yet, but the outcome so far is promising mainly due to the beneficial influence of sleeve gastrectomy on ghrelin level decrease and PYY hormone level increase. There have been papers published which reported that in some patients weight loss was insufficient and some even regained weight. Such patients needed reoperation. The options include gastric bypass, duodenal diversion or enhancing the restriction by placing a band in the upper part of the „sleeve”. Considering the fact that this method is used mainly in patients with BMI>50, with high perioperative risk, this two-stage approach is fully justified (20, 21).
Patients who undergo malabsorption surgery need to be monitored carefully, not only for the risk of surgical complications but also for deficiency disorders. All malabsorption surgery procedures used nowadays include components both quantitative (food amount limitation) and qualitative (limitation of absorption and digestion). Food intake limitation results from the existence of a (subcardial) pouch which has been created in the upper stomach with a capacity from 30 ml (gastric bypass) to 250 ml (biliopancreatic diversion). Digestion and absorption limitation is achieved by making a Roux loop, which separates the alimentary loop from the enzymatic loop; these combine to create a common digestive loop. Consequently, malabsorption surgery may result in the need for re-surgery because of anatomical changes within the stomach and intestines related to the previous surgery.
Insufficient weight loss or weight regain in patients after malabsorption surgery can result from:
– Breakdown of the staple line or gastro-gastric fistula formation between the dissected parts of the stomach (this does not apply to partial gastrectomy and excluding that part of the stomach from the food passage);
– Adaptive changes in the organism without visible anatomical pathologies leading to either the ability to take in more food (postprandial syndrome subsidence) or an increase in digestion and absorption of the food eaten.
The basis for further treatment is radiographic and endoscopic examinations of the upper part of the gastrointestinal tract. When the upper stomach part is enlarged, it can be reduced surgically by partial resection and formation of a new gastrointestinal anastomosis. When a false canal forms between the proximal and distal parts of the stomach, it should be separated, and in some patients, combined with circumference resection of the organ (22). Some researchers suggest that when there are no anatomical anomalies diagnosed within the upper segment of the alimentary tract, classical (proximal) gastric bypass should be converted into so-called circumferential (distal) gastric bypass (23). At present, such an operation is believed to consist of shortening the digestive loop to less than 100 cm.
One possible complication in patients after gastric bypass surgery is so-called marginal ulceration localized at the border of the gastro-intestinal anastomosis (24). When conservative treatment fails or such complications as bleeding, perforation or cicatricial stricture develop, surgery may become necessary. The therapy will depend on the diagnosed pathology, but it usually consists in resecting the anastomosis site and making a new anastomosis. Circumferential gastrectomy leads to a smaller marginal ulceration rate.
Anatomical changes which develop in the intestines as a result of gastric bypass surgery may lead to mechanical obstruction, which has to be treated surgically for life-saving indications. The most common cause is internal hernia (25). In patients operated on laparoscopically, the rate of mechanical obstruction is higher than in those treated with the classical method (26). This is connected with the fact that laparoscopy produces fewer intraperitoneal adhesions. It is worth noting that occlusion can affect the enzymatic loop, which can manifest as its dilatation, gastrectasia and, less frequently, constipation.
Malabsorption surgery may lead to nutritional deficiency syndromes, which may include protein deficiency (27). Patients in whom conservative treatment with nutrients containing digestive enzymes and easily assimilated proteins is ineffective can be potential candidates for surgical treatment. This situation is most common in patients with biliopancreatic diversion. Reoperation consists in prolongation of the digestive loop, with the length of the alimentary loop unchanged.
The scope of the present paper limits the possibility to discuss revisional surgery in greater detail. Still, the authors wish to emphasize that patients who have undergone surgical obesity treatment may always need reoperation. The likelihood for this situation increases over time that has elapsed since the primary surgery.
It is most advisable that patients should be operated on in centres where such procedures are performed on a daily basis. Sometimes there may be a need for operating on a patient urgently in the centre where the patient has appeared. The possible indication for reoperation may result from complications related to the previous surgical procedure, but they just as well can be independent of it.
Piśmiennictwo
1. Stanowski E, Wyleżoł M, Paśnik K: Laparoskopia w chirurgii bariatrycznej w Polsce – stan aktualny. Wideochir 2007; 2: 18-23.
2. Ramos AC et al.: Laparoscopic Duodenal-Jejunal Exclusion in the Treatment of Type 2 Diabetes Mellitus in Patients with BMI<30 kg/m(2) (LBMI). Obes Surg 2009; 19: 307-12.
3. Cohen R et al.: Laparoscopic Roux-en-Y gastric bypass for BMI<35 kg/m(2): a tailored approach. Surg Obes Relat Dis 2006; 2: 401-4.
4. Halverson JD et al.: Jejunoileal bypass for morbid obesity. A critical appraisal. Am J Med 1978; 64: 461-75.
5. Cegielski MM., Organ CH Jr, Saporta JA: Revision of intestinal bypass procedures. Surg Gynecol Obstet 1976; 142: 829-39.
6. LaFave JW, Alden JF: Gastric bypass in the operative revision of the failed jejuno-ileal bypass. Arch Surg 1979; 114: 438-44.
7. Griffen WO Jr et al.: Experiences with conversion of jejunoileal bypass to gastric bypass: its use for maintenance of weight loss. Arch Surg 1981; 116: 320-4.
8. Hanni CL et al.: Treatment of jejunoileal bypass failure by reanastomosis and gastroplasty in a single-stage procedure. Review of 47 cases. Am J Surg 1984; 50: 354-7.
9. Mason EE, Scott DH: Reoperation for failed gastric bypass procedures for obesity. Surg Clin North Am 1991; 71: 45-56.
10. Linner JH, Drew RL: Reoperative surgery – indications, efficacy, and long-term follow-up. Am J Clin Nutr 1992; 55: 606-610.
11. Linner JH: Surgery for morbid obesity. Springer Verlag New York 1984.
12. Slater GH, Fielding GA: Combining laparoscopic adjustable gastric banding and biliopancreatic diversion after failed bariatric surgery. Obes Surg 2004; 14: 677-82.
13. Behrns KE: Reoperative bariatric surgery: lessons learned to improve patient selection and results. Ann Surg 1993; 218: 646-653.
14. MacLean LD, Rhode BM, Forse RA: A gastroplasty that avoids stapling in continuity. Surgery 1993; 113: 380-8.
15. Nesset EM et al.: A two-decade spectrum of revisional bariatric surgery at a tertiary referral center. Surg Obes Relat Dis 2007; 3: 25-30.
16. Froilan Torres C et al.: Silastic band migration: an unusual complication following vertical banded gastroplasty. Endoscopy. 2003; 35: 193.
17. Foletto M et al.: Late gastric pouch necrosis after Lap-Band, treated by an individualized conservative approach. Obes Surg 2005; 15: 1487-90.
18. Wylezol M et al.: Intra-abdominal abscess in the course of intragastric migration of an adjustable gastric band: a potentially life-threatening complication. Obes Surg 2006; 16: 102-4.
19. Suter M et al.: Band erosion after laparoscopic gastric banding: occurrence and results after conversion to Roux-en-Y gastric bypass. Obes Surg 2004; 14: 381-6.
20. Fuks D et al.: Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery 2009; 145: 106-13.
21. Greenstein AJ, Vine AJ, Jacob BP: When sleeve gastrectomy fails: adding a laparoscopic adjustable gastric band to increase restriction. Surg Endosc 2009 Epub ahead of print.
22. Carrodeguas L et al.: Surg Obes Relat Dis 2005; 1: 467-74. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature.
23. Sugerman HJ, Kellum JM, DeMaria EJ: Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997; 1: 517-24.
24. Csendes A et al.: Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Obes Surg 2009; 19: 135-8.
25. Iannelli A et al.: Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007; 17: 1283-6.
26. Rogula T, Yenumula PR, Schauer PR: A complication of Roux-en-Y gastric bypass: intestinal obstruction. Surg Endosc 2007; 21: 1914-8.
27. Skroubis G et al.: Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg 2002; 12: 551-8.
otrzymano/received: 2009-04-01 zaakceptowano/accepted: 2009-06-03 Adres/address: *Mariusz Wyleżoł Department of Surgery, Military Institute of Avation Medicine Krasińskiego str. 54, 01-755 Warsaw tel.: (0-22) 685-22-08 e-mail: wylezol@inbox.com Pełna wersja artykułu Revisional bariatric surgery in patients who underwent surgical treatment for morbid obesity dostępna w Czytelni Medycznej Borgis. |
  Proszę kliknąć w wybraną okładkę aby przejść na stronę czasopisma
 |
Chcesz być na bieżąco? Polub nas na Facebooku: strona Wydawnictwa na Facebooku |