Abdelkader Hawasli

Management of renal allografts with multiple renal arteries resulting from laparoscopic living donor nephrectomy

Abstract:  Laparoscopic living donor nephrectomy (LLDN) has become an accepted procedure in many transplant centers. The placement of laparoscopic vascular staples can result in multiple short, small‐caliber renal arteries that the recipient surgeon must deal with to restore perfusion to all parts of the kidney. The incidence of multiple renal arteries resulting from LLDN, surgical management of multiple renal arteries, and the short‐ and long‐term graft functions were studied in 73 consecutive kidney recipients at a single center. Various techniques used for reconstruction are described, including the use of recipient internal iliac artery for the extension and reconstruction of small‐caliber, short renal vessels. Single‐artery allografts were compared with those with multiple arteries, with length of renal artery, warm ischemia time, hospital length of stay, operating time, creatinine levels, and 1 yr survival rates not found to be significantly different. The presence of multiple renal arteries should not exclude the possibility of using the left kidney for LLDN.

Kidney transplant complications and obesity

OBJECTIVE To determine the rate of graft failure and complications secondary to morbid obesity in kidney transplant patients at our institution. METHODS A retrospective study involving recipients renal transplants from 2002 to 2007. Patients were divided into 3 groups: group 1, body mass index (BMI) >35 underwent a diet plan and gained weight posttransplant; group 2, BMI >35 underwent successful diet modifications posttransplant; and group 3, BMI <35 did not undergo a diet regimen. RESULTS Sixty-six patients were studied. Group 1 patients, (n = 21, BMI >35) had higher postoperative complications, longer operative time, and longer hospital stay when compared with their obese counterparts group 3 (n = 23, BMI <35). We saw no significant change in postoperative complications between group 2 and group 3 (n = 22, BMI > 35). CONCLUSIONS Worse graft function and complications were seen with patients who gained weight post operatively. Conversely, a good outcome was seen with those patients that lost weight pre and post operatively. The results of this study may open the field for pretransplant weight loss procedures to improve quality of life, nutrition, and overall health of transplant candidates.

Remote Complications of Spilled Gallstones During Laparoscopic Cholecystectomy: Causes, Prevention, and Management

In the last 11 years (November 1989-December 2000), 5526 laparoscopic cholecystectomies were performed in a community residency training program. Two cases (0.04%) of remote complications secondary to spilled gallstones were identified. A 75-year-old woman presented with a sterile abscess in the abdominal wall containing gallstones 4 years and 4 months after an elective laparoscopic cholecystectomy. The second patient, a 43-year-old woman, presented with a subdiaphragmatic/subhepatic abscess containing gallstones. The abscess grew the same bacteria that were present 2 years and 3 months previously during a laparoscopic cholecystectomy for acute gangrenous cholecystitis. In both cases, pigmented gallstones were identified. Causes of gallstone spillage, means of prevention, and ways of managing this complication are discussed.

Single-incision laparoscopic cholecystectomy (SILC): a refined technique

BACKGROUND Reports of decreasing the number of incisions in laparoscopic procedures began appearing in the 1990s. A recent spark in pursuing such an approach has been accelerated by natural-orifice transluminal endoscopic surgery. METHOD Several modifications in performing single-incision laparoscopic cholecystectomy (SILC) were introduced until it was possible to develop a simple and safe technique. RESULTS SILC was completed in 61 of 71 operated patients. Fifty-five patients had SILC without cholangiography (average operative time, 49 minutes). Thirteen patients had SILC with cholangiography, 11 with negative results (average operative time, 67 minutes). Three patients needed additional trocars (bi-incision access surgery [BIAS]). None were converted to open procedures. Of the 69 patients with SILC or BIAS, 66 had same-day discharge, and 3 were discharged the following day. CONCLUSION SILC or BIAS is effective for gallbladder removal, with comparable lengths of stay, operative times, and safety as the traditional method, with better cosmetic results.

Early effects of bougie size on sleeve gastrectomy outcome.

BACKGROUND When performing sleeve gastrectomy, a bougie (32 to 60 French) is used. We evaluated 2 different bougie sizes on early postoperative outcomes and long-term weight loss. METHODS A 1-year prospective study was conducted on patients undergoing sleeve gastrectomy. In the first 6 months, patients had 32-French bougies (Group 1); in the second 6 months, they had 36-French bougies (Group 2). RESULTS We evaluated 131 patients. No intraoperative complications or mortality occurred. Postoperatively, Group 1 (n = 72) had a longer hospital stay (1.6 ± .8 vs 1.3 ± .5 days, P = .04) and used more Ondansetron for nausea than Group 2 (n = 59) (6.7 ± 8.0 vs 5.3 ± 4.5 mg, P = .2, respectively). Ten (14%) patients in Group 1 returned to the emergency department compared with 5 (9%) in Group 2. One-year percent excess weight loss was similar (73.0 ± 20.6% vs 71.1 ± 20.9%, P = .73, respectively). CONCLUSIONS The smaller bougie resulted in a longer hospital stay, with tendency toward increased nausea, more emergency department visits, and readmissions. Long-term weight loss was not affected.

Spontaneous resolution of massive laparoscopy-associated pneumothorax: the case of the bulging diaphragm and review of the literature.

A massive left-side pneumothorax was identified intraoperatively on the basis of bulging left hemidiaphragm toward the end of an uncomplicated laparoscopic Nissen fundoplication. There were no changes in ventilatory or hemodynamic parameters. The pneumothorax was observed, and nearly total spontaneous resolution occurred in the recovery room within 1 hour.

Controlling difficult pelvic bleeding with argon beam coagulator during laparoscopic ultra low anterior resection.

In recent years, the standard of care for lower rectal tumors has developed to include a total mesorectal excision, which provides optimal long-term results. There has been debate with regard to the best approach for lower rectal tumors, conventional open versus less invasive procedures. As the trend toward less invasive surgical procedures progresses, similar complications, which are seen in open cases, are being encountered, such as the notorious presacral fascia bleed. These are small vessels, which are difficult to locate and control. Surgical literature suggests different methods during laparoscopic procedures. These include: placing lap pads and holding pressure, placing saline bag, placing tacks, using bone wax, and electrocautry at different settings. We present a case of a 57-year-old male, positive for lymph node disease, who underwent laparoscopic ultra low anterior resection with total mesorectal excision and protective loop ileostomy.

The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study

INTRODUCTION Gallstones commonly develop after Roux-en-Y gastric bypass and other bariatric surgery; however, incidence of gallstone development after SG has not been adequately studied. METHODS We conducted a retrospective cohort study of patients who underwent SG at two institutions from January 1, 2011 to December 31, 2012. Patients with previous cholecystectomy, preexisting gallstones, gallbladder polyps, or the absence of preoperative abdominal imaging were excluded. Follow-up abdominal ultrasonography was performed once the patients achieved 80-lb weight loss, became symptomatic, or reached one-year post-surgery. The incidence of gallstones and symptomatic gallstones and/or bile sludge was calculated. Different parameters of early and late postoperative weight loss were compared between the patients who developed gallstones and those who did not. RESULTS During the study period, 253 underwent laparoscopic sleeve gastrectomy. Ultimately, 96 patients met inclusion criteria and were evaluated. The incidence of gallstone formation was 47.9% (46/96), and the incidence of symptomatic gallstones was 22.9% (22/96). None of the weight loss parameters during the early and late postoperative period were significantly different between the patients who developed gallstones and those who did not. CONCLUSION Gallstones are a common complication after rapid weight loss from SG. Our data suggest that gallstone formation during the weight loss period is not associated with amount or rate of weight loss both during the early or late postoperative period.

Factors that influence lymph node retrieval in the surgical treatment of colorectal cancer: a comparison of the laparoscopic versus open approach

BACKGROUND The purpose of this study was to determine whether surgical approach and patient demographics are important factors that influence lymph node retrieval. METHODS This was a retrospective review of patients receiving surgical treatment for colorectal cancer at a single institution. RESULTS Two hundred three patients underwent resection for colorectal cancer. The total number of lymph nodes recovered and the number of lymph nodes involved were similar in both the laparoscopic group and the open group. Patients who had right-sided colon resection had a higher total number of lymph nodes recovered. There was no effect of age, sex, race, or body mass index (BMI) on the total number of lymph nodes harvested or on the number of positive lymph nodes. CONCLUSIONS Adequate regional lymphadenectomy for colorectal cancer can be successfully performed using a laparoscopic approach. Patient demographics did not make a difference in the number of total or positive lymph nodes recovered.

Laparoscopic Management of Severe Reflux After Sleeve Gastrectomy, in Selected Patients, Without Conversion to Roux-en-Y Gastric Bypass

BACKGROUND Treatment of severe reflux after laparoscopic sleeve gastrectomy (LSG) may require conversion to Roux-en-Y gastric bypass (RYGB). We conducted a pilot study to evaluate the feasibility and effectiveness of performing laparoscopic anterior fundoplication with posterior crura approximation (LAF/pCA), in selected patients, to correct the reflux without conversion to RYGB. PATIENTS AND METHODS From October 2012 to April 2013, 6 patients with confirmed severe de novo reflux after LSG were treated with LAF/pCA. RESULTS All patients were females with a mean age of 41.5±14.2 years. All patients had lost weight after initial LSG. The percentage excess body mass index (BMI) loss (%EBL) was 61.2±33.2%. The mean time from the initial LSG to LAF/pCA was 33.2±12.5 months. Four patients had reduction of gastric fundus size. One patient required resleeving. Reflux resolved immediately in all patients with a follow-up of 18.5±2.7 months. All patients continued to lose weight, with %EBL reaching 75.5±22.9% and a mean BMI of 32±7.3 kg/m(2). CONCLUSIONS LAF/pCA with reduction of gastric fundus size, when needed, may be considered an alternative option to correct severe reflux after LSG in selected patients.