Anna Ibele

Adolescent Bariatric Surgery

Obesity has become an increasingly serious problem in pediatric and adolescent populations in the United States. Although bariatric surgery has been offered to morbidly obese adolescents for the past several decades, it remains controversial. However, the benefits of weight loss surgery in this population have been realized, particularly its long-term physical and emotional effects on adolescents. This article reviews the demographics and health implications of adolescent obesity, describes the most common adolescent bariatric surgical procedures and their outcomes, discusses the ethical issues involved in elective surgery in this population, and outlines the key components of an adolescent bariatric surgical program.

Effect of circular staple line buttressing material on gastrojejunostomy failure in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND To determine the effect of bovine pericardium strip (BPS) reinforcement of the circular stapler on the gastrojejunostomy leak rates and staple line failure after laparoscopic Roux-en-Y gastric bypass (LRYGB) at a university hospital in the United States. Gastrojejunostomy leak after LRYGB is a devastating complication. Various techniques, including buttressing the gastrojejunostomy staple line with biomaterial, have been used in an effort to minimize leaks. METHODS A total of 350 consecutive patients underwent LRYGB without staple line buttressing. After this initial experience, BPS reinforcement of the gastrojejunostomy was conducted in 81 consecutive patients. BPS reinforcement was not used for the final 69 consecutive patients in this 500 patient series. Circular staple line failures (intraoperative immediate and complete failure of the anastomosis) and leaks were evaluated retrospectively. RESULTS Three leaks (and no intraoperative staple line failures) occurred in 419 patients without BPS buttressing, all in the first 100 cases of our experience, and 3 leaks and an anastomotic staple line failure occurred in the 81 patients with BPS buttressing (.7% versus 4.9%, P = .02). The body mass index and other potential leak risk factors did not differ between the 2 groups. CONCLUSION In our experience, buttressing of the circular staple line with BPS during LRYGB was associated with an increased staple line adverse event rate. BPS buttressing of the gastrointestinal circular staple lines should be used with caution.

Identification of novel clinical factors associated with hepatic fat accumulation in extreme obesity.

Objectives. The accumulation of lipids stored as excess triglycerides in the liver (steatosis) is highly prevalent in obesity and has been associated with several clinical characteristics, but most studies have been based on relatively small sample sizes using a limited set of variables. We sought to identify clinical factors associated with liver fat accumulation in a large cohort of patients with extreme obesity. Methods. We analyzed 2929 patients undergoing intraoperative liver biopsy during a primary bariatric surgery. Univariate and multivariate regression modeling was used to identify associations with over 200 clinical variables with the presence of any fat in the liver and with moderate to severe versus mild fat accumulation. Results. A total of 19 data elements were associated with the presence of liver fat and 11 with severity of liver fat including ALT and AST, plasma lipid, glucose, and iron metabolism variables, several medications and laboratory measures, and sleep apnea. The accuracy of a multiple logistic regression model for presence of liver fat was 81% and for severity of liver fat accumulation was 77%. Conclusions. A limited set of clinical factors can be used to model hepatic fat accumulation with moderate accuracy and may provide potential mechanistic insights in the setting of extreme obesity.

Urgent laparoscopic repair of acutely symptomatic PEH is safe and effective

BackgroundAcute incarceration of paraesophageal hernias (PEHs) requiring urgent or emergent surgery is rare. Patients are often elderly with significant comorbidities and have historically been treated with open abdominal or thoracic incisions. Our study was designed to evaluate the feasibility, safety, and efficacy of laparoscopic paraesophageal hernia repair (LPEHR) in patients with PEH and acute gastric volvulus.MethodsWe reviewed our prospectively maintained database and identified 269 patients who underwent an initial LPEHR between January 2003 and January 2012. Patients were divided into group A (acute), group B (age- and comorbidity-matched 1:3), and group C (all elective repairs). Group A included those admitted with acute symptoms related to PEH and underwent urgent repair. Patient age, Charlson score, operative time, length of stay (LOS), morbidity, mortality, and recurrence rates were compared.ResultsPatients who underwent urgent LPEHR had a higher perioperative morbidity rate than the elective and matched groups. The overall mortality rate was low and no statistical difference was found between groups A, B, and C. LOS in group A was longer than groups B and C. The need for ICU admission was also higher in group A. There was no statistical difference in recurrence rates.ConclusionsHistorically, patients presenting with acute symptoms related to PEH have required open repair, which is associated with significant morbidity and mortality. The acute group was older and sicker than our elective LPEHR patients and had more adverse events resulting in a longer LOS, even when compared with comorbidity-matched elective patients. However, the LOS remained shorter than that reported for open repair and there was no mortality. The recurrence rates in all groups were low and comparable to elective repairs.

Survival of a profoundly hydropic fetus with a sacrococcygeal teratoma delivered at 27 weeks of gestation for maternal mirror syndrome

The development of hydrops fetalis and maternal mirror syndrome in the setting of fetal sacrococcygeal teratoma (SCT) carries a grave prognosis. Fetal surgery is not typically offered for hydropic fetuses beyond 26 weeks of gestational age. Few options exist for these families, and they are typically counseled to continue pregnancy until delivery is necessary for maternal indications or the fetus is 30 weeks old. Although a number of series report the survival of hydropic SCT infants delivered after 30 weeks of gestation, a paucity of information is available regarding the outcome of hydropic SCT infants delivered between 26 and 30 weeks of gestation. We now report successful postpartum resection and survival of a hydropic fetus delivered at 27 weeks for maternal mirror syndrome that may assist in counseling families in similar situations.

Portal vein thrombus after pediatric proctocolectomy with ileoanal anastomosis

In adults, mesenteric venous thrombosis with extension into the portal system is a known complication of total proctocolectomy with pouch ileoanal anastomosis. Although frequently reported in adults, this complication is rare in pediatric patients undergoing this operation. We report 2 cases of adolescent patients with ulcerative colitis who experienced portal vein thrombosis after this procedure. Both were treated with systemic anticoagulation therapy with complete resolution of their clots. We recommend that mesenteric/portal venous thrombosis be considered in the differential diagnosis in any child presenting with fever, abdominal pain, and leukocytosis after restorative proctocolectomy with ileal pouch anastomosis and that imaging obtained to evaluate abdominal complaints in this population be directed toward ruling out this complication.

Preoperative use of incretins is associated with increased diabetes remission after RYGB surgery among patients taking insulin: a retrospective cohort analysis.

OBJECTIVE The main goal of this study was to determine the effects of incretins on type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery for patients taking insulin. BACKGROUND Type 2 diabetes is a chronic disease with potentially debilitating consequences. RYGB surgery is one of the few interventions that can remit T2D. Preoperative use of insulin, however, predisposes to significantly lower T2D remission rates. METHODS A retrospective cohort of 690 T2D patients with at least 12 months follow-up and available electronic medical records was used to identify 37 T2D patients who were actively using a Glucagon-like peptide 1 (GLP-1) agonist in addition to another antidiabetic medication, during the preoperative period. RESULTS Here, we report that use of insulin, along with other antidiabetic medications, significantly diminished overall T2D remission rates 14 months after RYGB surgery (9%) compared with patients not taking insulin (56%). Addition of the GLP-1 agonist, however, increased significantly T2D early remission rates (22%), compared with patients not taking the GLP-1 agonist (4%). Moreover, the 6-year remission rates were also significantly higher for the former group of patients. The GLP-1 agonist did not improve the remission rates of diabetic patients not taking insulin as part of their pharmacotherapy. CONCLUSIONS Preoperative use of antidiabetic medication, coupled with an incretin agonist, could significantly improve the odds of T2D remission after RYGB surgery in patients also using insulin.

A Novel Technique for Wound Protector Deployment and Efficient Specimen Extraction Following Laparoscopic Sleeve Gastrectomy

Challenges of specimen extraction during laparoscopic sleeve gastrectomy and other resectional laparoscopic procedures can often be proven to be time consuming and frustrating, and the risk of wound infection and port site tumor implantation increases. In this paper, we discuss our experience with an efficient approach to specimen extraction utilizing a novel technique for deployment of a very small self-expanding wound protector through a 12- or 15-mm port. We also report our observations with regard to the learning curve of this technique and the influence of BMI to retractor insertion times and specimen extraction times during laparoscopic sleeve gastrectomy.

Laparoscopic Roux-en-Y Gastric Bypass

Obesity is a major health problem in the United States. The Framingham Heart Study group recently published that the incidence of obesity (BMI >30) in men increased from 5.8 % in the 1950s to 14.8% in the 1990s and the incidence in women has increased from 3.9 to 14% in the 1990s [1]. Obesity is a contributing factor in multiple health conditions including type 2 diabetes mellitus, coronary artery disease, dyslipidemia, stroke, sleep apnea, osteoarthritis, and some cancers. Morbid obesity is not only costly in terms of a patient’s overall quality of life, but also has important financial repercussions. A study of national costs attributed to an overweight body habitus (BMI 25-29.9) and obesity (BMI > 30) projected medical expenses due to these conditions to account for approximately 92.6 billion dollars in 2002 [2, 3].