Faisal G. Qureshi

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity

BackgroundThe surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique.MethodsIn this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002–February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP).ResultsDuring this time, 126 patients underwent LSG (53% female). The mean age was 49.5 ± 0.9 years, and the mean BMI was 65.3 ± 0.8 (range 45–91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 ± 0.3 with a median of 10 (range 3–17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 ± 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 ± 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 ± 0.8 months. The mean and median hospital stays were 3 ± 1.7 and 2.5 (range 2–7) days, respectively. There were no deaths, and the incidence of major complications was 8%.ConclusionThe staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

Outcome analysis of neonates with congenital diaphragmatic hernia treated with venovenous vs venoarterial extracorporeal membrane oxygenation.

PURPOSEnVenoarterial extracorporeal membrane oxygenation (ECMO) (VA) is used more commonly in neonates with congenital diaphragmatic hernia (CDH) than venovenous ECMO (VV). We hypothesized that VV may result in comparable outcomes in infants with CDH requiring ECMO.nnnMETHODSnWe retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) database (1991-2006). Multivariate logistic regression analyses were used to compare VV- and VA-associated mortality.nnnRESULTSnFour thousand one hundred fifteen neonates required ECMO, with an overall mortality rate of 49.6%. Venoarterial ECMO was used in 82% and VV in 18% of neonates. Pre-ECMO inotrope use and complications were equivalent between VA and VV. The mortality rate for VA and VV was 50% and 46%, respectively. After adjusting for birth weight, gestational age, prenatal diagnosis, ethnicity, Apgar scores, pH less than 7.20, Paco(2) greater than 50, requiring high-frequency ventilation, and year of ECMO, there was no difference in mortality between VV vs VA. Renal complications and on-ECMO inotrope use were more common with VV, whereas neurologic complications were more common with VA. The conversion rate from VV to VA was 18%; conversion was associated with a 56% mortality rate.nnnCONCLUSIONnThe short-term outcomes of VV and VA are comparable. Patients with CDH who fail VV may be predisposed to a worse outcome. Nevertheless, VV offers equal benefit to patients with CDH requiring ECMO while preserving the native carotid.

A Diagnostic Delay of 5 Hours Increases the Risk of Death After Blunt Hollow Viscus Injury

BACKGROUNDnHollow viscus injuries (HVI) are uncommon after blunt trauma, and accomplishing a timely diagnosis can be difficult. Time to operative intervention has been implicated as a risk factor for mortality, but reports are conflicting.nnnMETHODSnAll blunt trauma admissions to an academic level 1 trauma center from January 1992 to September 2005 were retrospectively reviewed. Patients with a diagnosis of blunt HVI were included. Patients who died within 24 hours were excluded. Data regarding patient demographics, injuries, time from admission until laparotomy, length of stay, and mortality were recorded, and a multivariate analysis to determine independent risk factors for mortality was carried out. A p < 0.05 was considered significant.nnnRESULTSnOf 35,033 blunt trauma admissions, there were 195 (0.6%) HVI patients with the following characteristics (data expressed as mean +/- 1 SD): mean age of 35 years +/- 16 years, Injury Severity Score of 17 +/- 11, time from admission to laparotomy of 5.9 hours +/- 5.8 hours, operative blood loss of 1500 mL +/- 1800 mL, and length of stay of 19 days +/- 23 days. Twelve percent presented with a systolic pressure <90 mm Hg and 9% died. Independent risk factors for mortality were age (odds ratio [OR] = 1.04, p = 0.005), Abdominal Abbreviated Injury Score (OR = 2.5, p = 0.011), the presence of a significant extra-abdominal injury (OR = 3.4, p = 0.043), and a delay of more than 5 hours between admission and laparotomy (OR = 3.2, p = 0.0499). Eighty-six percent of the deaths in patients who had a delay of >5 hours were because of abdominal-related sepsis.nnnCONCLUSIONnHVI occurred in less than 1% of all blunt trauma admissions. Delays in operative intervention are associated with an increased mortality. A high index of suspicion is needed to make a timely diagnosis and minimize risk.

Early results after laparoscopic sleeve gastrectomy in adolescents with morbid obesity

BACKGROUNDnObesity has been identified as one of the most important public health concerns in both children and adolescents. Unfortunately, even the most comprehensive and aggressive multidisciplinary weight management programs have shown only modest weight loss results. There has been increasing enthusiasm for bariatric surgery for adolescent patients with morbid obesity. Because of the relatively high morbidity and mortality associated with gastric bypass surgery, we have begun to explore laparoscopic sleeve gastrectomy as an alternative. We hypothesized that it would be a safe and effective short-term strategy.nnnMETHODSnWe have prospectively collected data from all patients undergoing bariatric surgery at our institution since the inception of our adolescent weight loss surgery program in January 2010. Baseline data collected included age, gender, race/ethnicity, height, weight, body mass index, and comorbid conditions. Postoperative data collected included the type of operation, length of stay, operative morbidity, the need for reoperation, and percent excess weight loss and body mass index at 3-month intervals.nnnRESULTSnTwenty-three patients have undergone laparoscopic sleeve gastrectomy at our institution since January 2010. Of these, 18 were female and 5 were male. The mean age was 17.3 ± 1.5 years of age. The mean preoperative weight was 149 ± 30 kg with a body mass index of 52 ± 9 kg/m(2). There were no intraoperative complications, and the only postoperative complication has been pancreatitis in 1 patient. The mean length of stay was 2.2xa0±xa01.1 days. The mean follow-up was 10.9xa0±xa07.4 months. The percent excess weight loss at 3 months, 6 months, and 1 year postoperatively was 32%, 38%, and 40%, respectively, in those who had reached these time points.nnnCONCLUSIONnLaparoscopic sleeve gastrectomy is a safe operation for adolescent patients with morbid obesity and represents an effective early treatment strategy with approximately 40% excess weight loss at 6 months and 1 year of follow-up. Because of the minimal morbidity associated with laparoscopic sleeve gastrectomy, it may be the optimal non-device surgical option for this select group of adolescent patients.

Comparative Analysis of Chest Tube Thoracostomy and Video-Assisted Thoracoscopic Surgery in Empyema and Parapneumonic Effusion Associated with Pneumonia in Children

BACKGROUNDnControversy exists regarding the optimal management strategy for children having empyema or parapneumonic effusion as a complication of pneumonia. We hypothesized that video-assisted thoracoscopic surgery (VATS)-assisted drainage of pleural fluid and debridement of the pleural space is superior to a chest tube alone in the management of these patients. We further identified predictive factors-namely, presentation, radiographic findings, antibiotic usage, and pleural fluid features-that could predict the need for VATS rather than primary chest tube drainage.nnnMETHODSnForty-nine pediatric patients with pneumonia complicated by parapneumonic effusion or empyema treated at the Childrens Hospital of Pittsburgh (1997-2003) were divided into three groups according to the therapy instituted: Primary chest tube, chest tube followed by VATS, or primary VATS. The groups were analyzed in terms of demographics and outcome, as judged by pleural fluid analysis and hospital resource utilization. Demographic and outcome data were compared among groups using one-way analysis of variance and the Student t-test.nnnRESULTSnAll groups were similar with respect to demographics and initial antibiotic usage. Patients undergoing primary VATS had a higher initial temperature, whereas radiographic findings of mediastinal shift and air bronchograms were more likely to be found in patients who underwent primary chest tube placement. Patients undergoing primary VATS demonstrated a significantly shorter total stay and lower hospital charges than the other groups. Forty percent of children started on chest tube therapy failed even with subsequent VATS, necessitating a significantly longer hospital course (18 +/- 3 vs. 11 +/- 0.8 days; p < 0.05) and higher hospital charges (

Treatment of refractory gastroesophageal reflux disease with radiofrequency energy (Stretta) in patients after Roux-en-Y gastric bypass

50,000 +/- 7,000 vs.

Laparoscopic Adrenalectomy in Children: A Multicenter Experience

29,000 +/- 1000) than those having primary VATS.nnnCONCLUSIONSnPatients treated by primary VATS had a shorter stay and lower hospital charges than patients treated by chest tube and antibiotic therapy alone. There were no demographic, physiologic, laboratory, or chest radiographic data that predicted the selection of VATS as an initial treatment. These data suggest a strategy of primary VATS as first-line treatment in the management of empyema or parapneumonic effusion as a complication of pneumonia in pediatric patients.

Thoracoscopic Repair of Neonatal Diaphragmatic Hernia

BackgroundMorbid obesity is associated with gastroesophageal reflux disease (GERD), which, in most cases, completely resolves after Roux-en-Y gastric bypass (RYGB). Patients with persistent or recurrent symptoms have limited surgical options. This study sought to evaluate the application of the Stretta procedure for patients with refractory GERD.MethodsThe medical records of all patients who underwent Stretta for refractory GERD after RYGB were reviewed. Demographic, preoperative, and postoperative reflux data were collected. Data are presented as mean ± standard error of the mean. The t-test was used for comparison purposes.ResultsOf 369 patients, 7 received Stretta 27 ± 6 months after RYGB. All were women with a mean age of 49 ± 2 years. All the patients had experienced prebypass GERD symptoms for a duration of 45 ± 8 months. The mean prebypass body mass index was 45 ± 2 kg/m2, and this was reduced to 29 ± 2 kg/m2 after laparoscopic RYGB (p < 0.001). Before Stretta, all patients underwent a 48-h Bravo pH study, which demonstrated reflux with a mean fraction time of 7% ± 2% for pH lower than 4. After Stretta, five patients had complete resolution of their symptoms, with normalization of pH studies (mean fraction time of 3% ± 0% for pH < 4). The follow-up period after Stretta was 20 ± 2 months. One patient did not have adequate relief of symptoms after Stretta, and one patient was lost to follow-up evaluation.ConclusionStretta is a valid option in the treatment of persistent GERD for patients who have undergone gastric bypass. Further study is required to evaluate the long-term efficacy of this procedure.

The changing population of the United States and use of extracorporeal membrane oxygenation

INTRODUCTIONnLaparoscopic adrenalectomy is now being recognized as the standard approach for adrenalectomy for benign lesions in adults. The published experience in children and adolescents has been limited to sporadic small case series. Therefore, we conducted a large multicenter review of children who have undergone laparoscopic adrenalectomy.nnnMETHODSnAfter Institutional Review Boards approval, a retrospective review was conducted on all patients who have undergone laparoscopic adrenalectomy at 12 institutions over the past 10 years. Operative times included unilateral adrenalectomy without concomitant procedures.nnnRESULTSnAbout 140 patients were identified (70 males [50%]). Laterality included 76 (54.3%) left-sided lesions, 59 (42.1%) right, and 5 (3.6%) bilateral. Mean operative time was 130.2 ± 63.5 minutes (range 43-406 minutes). The most common pathology was neuroblastoma in 39 cases (27.9%), of which 23 (59.0%) had undergone preoperative chemotherapy. Other common pathology included 30 pheochromocytomas (21.4%), 22 ganglioneuromas (15.7%), and 20 adenomas (14.3%). There were 13 conversions to an open operation (9.9%). Most conversions were because of tumor adherence to surrounding organs, and tumor size was not different in converted cases (P=.97). A blood transfusion was required in 2 cases. The only postoperative complication was renal infarction after resection of a large neuroblastoma that required skeletonization of the renal vessels. At a median follow-up of 18 months, there was only one local recurrence, which was in a patient with a pheochromocytoma.nnnCONCLUSIONSnThe laparoscopic approach can be applied for adrenalectomy in children for a wide variety of conditions regardless of age with a 90% chance of completing the operation without conversion. The risk for significant blood loss or complications is low, and it should be considered the preferred approach for the majority of adrenal lesions in children.

Laparoscopic vertical sleeve gastrectomy for adolescents with morbid obesity

INTRODUCTIONnThe use of minimally invasive surgery (MIS) in the neonatal population is increasing. Thoracoscopic intervention for congenital diaphragmatic hernia (CDH) is no exception. In this report, we describe our initial experience with thoracoscopic repair of left-sided diaphragmatic defects in neonates.nnnMATERIALS AND METHODSnWe performed retrospective chart reviews on all neonates who underwent thoracoscopic repair of CDH between November 2004 and January 2008. Neonates that underwent thoracoscopic repair were physiologically stable with resolved pulmonary hypertension and minimal to moderate ventilatory support. They had no associated cardiac anomalies.nnnRESULTSnWe identified 15 neonates with CDH who underwent thoracoscopic repair during the study period. Ten neonates underwent primary repair of the diaphragmatic defect. Five neonates with large defects required closure with a synthetic patch, which was placed thoracoscopically. The average operating room time was 134 minutes. There were no instances of intraoperative respiratory or cardiac instability. Three patients had a recurrence. One recurrence was seen after thoracoscopic patch repair. Two recurrences occurred following primary repair of left diaphragmatic hernias. There were no deaths. Follow-up has been 4-40 months.nnnCONCLUSIONSnNeonatal MIS for CDH should be limited to stable patients. The ideal candidate is the newborn without associated anomalies, not requiring extracorporeal membrane oxygenation, on minimal ventilatory support, and without evidence of pulmonary hypertension. It is technically possible to perform thoracoscopic repair with a patch.