Daniel T. McKenna

Gastric electrical stimulation is an effective and safe treatment for medically refractory gastroparesis

BACKGROUND Gastroparesis is characterized by delayed gastric emptying in the absence of obstruction. Common symptoms include nausea, vomiting, and abdominal pain. Severe gastroparesis can result in recurrent hospitalizations, malnutrition, and even death. Gastric electrical stimulation (GES) is a low morbidity treatment that may be effective in patients who are refractory to medical therapy. METHODS For a period of more than 35 months, 19 GES systems were implanted laparoscopically for refractory gastroparesis of diabetic (DG, n = 10), idiopathic (IG, n = 6), or postsurgical (PSG, n = 3) etiology. Total gastroparesis symptom scores (TSS) and weekly vomiting frequency were assessed. Gastric emptying studies were attained preoperatively and after 6 months. RESULTS Mean follow-up was 38 weeks. There were no major complications. Within 6 weeks, frequency of vomiting decreased in 75% of DG (6/8) and 100% of IG (4/4) patients. No PSG patient complained of vomiting preoperatively. Mean TSS scores improved significantly at all intervals out to 1 year. Gastric emptying studies normalized in 80% of DG patients but in only 1 of the 6 patients with gastroparesis due to other causes. CONCLUSION GES therapy can lead to improvement in symptoms of gastroparesis and frequency of vomiting within 6 weeks. This therapy is a low morbidity treatment option that may help patients whose symptoms fail to improve with medical therapy.

Iatrogenic intestinal and mesenteric injuries with small bowel volvulus following use of barbed suture during laparoscopic myomectomy

This is a case report of a patient who developed major intestinal complications after the utilization of barbed sutures for an off-label indication. The report serves as a warning for patients and surgeons of the potential injuries that may be caused by the use of new products in unapproved indications.

Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss.

BACKGROUND Patients having previous bariatric surgery are at risk for weight regain and return of co-morbidities. If an anatomic basis for the failure is identified, many surgeons advocate revision or conversion to a Roux-en-Y gastric bypass. The aim of this study was to determine whether revisional bariatric surgery leads to sufficient weight loss and co-morbidity remission. PATIENTS AND METHODS From 2005-2012, patients undergoing revision were entered into a prospectively maintained database. Perioperative outcomes, including complications, weight loss, and co-morbidity remission, were examined for all patients with a history of a previous vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGB). RESULTS Twenty-two patients with a history of RYGB and 56 with a history of VBG were identified. Following the revisional procedure, the RYGB group experienced 35.8% excess weight loss (%EWL) and a 31.8% morbidity rate. For the VBG group, patients experienced a 46.2% %EWL from their weight before the revisional operation with a 51.8% morbidity rate. Co-morbidity remission rate was excellent. Diabetes (VBG:100%, RYGB: 85.7%), gastroesophageal reflux disease (VBG: 94.4%, RYGB: 80%), and hypertension (VBG: 74.2%, RYGB:60%) demonstrated significant improvement. CONCLUSION Revision of a failed RYGB or conversion of a VBG to a RYGB provides less weight loss and a higher complication rate than primary RYGB but provides an excellent opportunity for co-morbidity remission.

Laparoscopic Transgastric Gastroplasty: A Novel Technique for a Large Esophagogastric Fistula

Esophagogastric fistula is a rare complication related to severe inflammation at the gastroesophageal junction. Most causes are related to severe gastroesophageal reflux disease, previous surgery, or malignancy. This is the case of a 72-year-old man who had a laparoscopic Nissen fundoplication. He developed an esophageal obstruction from an intraesophageal pledget. It was removed laparoscopically, and the esophagotomy was buttressed with a Nissen fundoplication. Two months later he developed severe dysphagia, and an esophagogastric fistula was diagnosed. This was a large fistula measuring 20 mm in diameter. A novel hybrid technique was used to divide the fundoplication. Under endoscopic guidance, a 12-mm balloon-tipped trocar was inserted transgastrically. A linear-cutting surgical stapler was used to divide the fundoplication and reopen the gastroesophageal junction. The patient had no further dysphagia or gastroesophageal reflux.