Fernando Dip

The Surgical Management of Complex Fistulas After Sleeve Gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) is gaining acceptance as the preferred option for treating obesity. Risks of leak and subsequent fistula after sleeve gastrectomy still present significant concerns in clinical practice. This current series presents unusual fistulas post-LSG and their surgical management.MethodsThe series presents chronic leaks that have progressed into fistulas. Three patients with fistulas are presented: gastrocolic, gastropleural, and gastrosplenic. Surgical intervention was warranted in all cases with en-bloc resection of the fistula with subtotal gastrectomy and Roux-en-Y esophagojejunostomy reconstruction. A subtotal colectomy with ileo-descending colon anastomosis was additionally necessary in the gastrocolic patient.ResultsThe patients with the gastropleural and gastrosplenic fistulas were discharged home on postoperative Day 6 and Day 7, respectively. The patient with the gastrocolic fistula had an extended postoperative hospital course and was discharged home on postoperative Day 35. All cases were negative for staple line leaks. To date, the fistulas healed with no recurrence.ConclusionsEn-bloc resection of the fistula with proximal gastrectomy and Roux-en-Y esophagojejunostomy (PGRYEJ) is a surgical option to treat chronic staple line leakage when non-operative therapy is rendered ineffective. Adequate preoperative planning with optimization of nutritional status and control of local and systemic sepsis is paramount for ultimate success. A symptomatic leak requires immediate operation regardless of the time interval between the primary sleeve operation and appearance of the leak.

Cutting Edge in Thyroid Surgery: Autofluorescence of Parathyroid Glands

BACKGROUND Identification of parathyroid glands may be challenging during thyroid and parathyroid surgery. Accidental resection of the glands may increase the morbidity of the surgery. The aim of this study was to evaluate accuracy in identification of autofluorescent parathyroid glands with the use of near infrared light in real time. STUDY DESIGN Patients undergoing thyroid and parathyroid surgery between June and August 2015 were included in the study. During the procedure, the surgical field was exposed to near infrared laser light in order to analyze the intensity of the fluorescence of different tissues (parathyroid glands, thyroid glands, and background). Surgical images were recorded and analyzed. RESULTS Twenty-eight patients were included in the study. Nineteen patients were women and 9 were men. Seven patients had primary hyperparathyroidism, 4 had hyperthyroidism, 3 had goiters, and 11 had thyroid cancer. Three patients had mixed pathologies, including 2 patients with thyroid cancer and primary hyperparathyroidism and 1 patient with goiter and primary hyperparathyroidism. Identification of autofluorescent parathyroid glands was achieved in all patients with near infrared light. The mean fluorescent intensity of parathyroid glands was 40.6 (±26.5), thyroid glands 31.8 (±22.3), and background 16.6 (±15.4). Parathyroid glands demonstrated statistically higher fluorescence intensity compared with the thyroid gland and background (p < 0.0014). No postoperative hypocalcemia or other complications related to the surgery were registered. CONCLUSIONS Visualization of autofluorescent parathyroid glands with the use of near infrared light allows high rates of parathyroid gland identification and could be a safe, feasible, and noninvasive method for intraoperative identification of parathyroid glands in real time. Further clinical studies must be performed to determine the cost-effectiveness and clinical application of this method.

Increased identification of parathyroid glands using near infrared light during thyroid and parathyroid surgery

BackgroundParathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL).Materials and methodsAll patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis.ResultsSeventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026).ConclusionThe use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.

Comparison between major and minor surgical procedures for the treatment of chronic staple line disruption after laparoscopic sleeve gastrectomy.

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become the most common weight loss surgery procedure. The procedures most dreaded surgical complication is staple-line disruption (SLD). So far, no definitive treatment modality has been established for this complication. OBJECTIVES The aim of this study is to review the treatment options used at our institution for patients with SLD after LSG and to evaluate the outcome of different interventions. METHODS A retrospective review of a prospectively collected database of all patients who underwent SLD between January 2005 and April 2014 was performed. SLD was defined as a leak identified on computed tomography or upper gastrointestinal series. We compared the cure rate between a major surgical procedure and patients treated with a variety of other minor treatment modalities. Special focus is given to the technique of proximal gastrectomy with Roux-en-Y esophagojejunostomy (PGEJ). The procedure consists of the en bloc resection of the proximal stomach immediately proximal to the gastroesophageal junction and including the fistulous tract. The jejunum is transected 50 cm distal to the ligament of Treitz and reconstruction of the gastrointestinal tract is performed with a Roux-en-Y esophagojejunostomy. RESULTS Thirty-one patients had SLD after their LSG. Patients were divided into 2 groups based on the treatment modality: Group A (PGEJ) and Group B (minor surgical procedure). Group A (n = 19) had 1 releak. Group B (n = 11) had 5 releaks. The cure rate for patients who underwent PGEJ was 94.7%. The cure rate for patients who were treated with a different approach was 54.5% (P = .01). CONCLUSION Our experience demonstrates that the cure rate of PGEJ is high. Minor surgical procedures are effective in approximately half of the patients, so when the leak becomes chronic, PGEJ can provide a long-term solution.

Ureter Identification Using Methylene Blue and Fluorescein

The use of a multimodal optical system that expands the surgeon’s light spectrum of view can improve surgical performance making structures clearly visible during laparoscopic and open surgery. This allows for shorter procedural duration and improved prevention and incidence of ureteral injury associated with complex pelvic surgery. Optical imaging using invisible NIR fluorescent light has several advantages over currently available intraoperative techniques. First, visualization of the ureters does not require ionizing radiation, and uses only safe wavelengths of light for ample excitation. Secondly, because fluorescence emission is invisible to the human eye, the surgical field is not stained or changed in any way. The blue dyes that are currently used stain the surgical field and have relatively poor contrast. Thirdly, imaging can be performed in real-time (up to 15 frames per second) with the merged image from the color video and NIR fluorescent cameras providing anatomical landmarks that are easily identifiable. More work is needed to identify the optimal contrast agent and light wavelength with which it is most optimally visualized. Overall, this field of knowledge is of great interest and reports a great growing potential.

Staple line as a cause of unusual early internal hernia after appendectomy

The use of mechanical stapling devices in laparoscopic appendectomies has become a common practice. Occasionally, the retained staples have been described to cause adhesions that might result in bowel obstruction. Early bowel obstruction after routine abdominal surgery should be closely investigated and might warrant early re-exploration. We present a rare case of small bowel obstruction caused by a staple line adhesive band one week after appendectomy. A 46-year-old female underwent laparoscopic appendectomy for uncomplicated appendicitis. A linear endoscopic stapling device was utilized during the procedure. The patient was discharged without complication. One week later, the patient presented to the emergency room for abdominal pain and she was discharged after adequate pain control. Several hours later she returned with similar symptoms, and she was diagnosed with distal small bowel obstruction by computed tomography scan. During the diagnostic laparoscopy there was an internal hernia through a defect created by the appendiceal staple line and the adjacent small bowel mesentery. After reduction of the hernia, the small bowel venous drainage improved, and no intestinal resection was necessary. The offending staple was removed and the staple line covered with omentum. The patient had complete resolution of symptoms and she was discharged the following day. No perioperative complications occurred. Mechanical staplers are routinely used in laparoscopic appendectomy. The staple line should be inspected at the end of the procedure to confirm the absence of free, unformed staples that can generate adhesions and postoperative complications.

Fluorescence Cholangiography in Laparoscopic Cholecystectomy Experience in Argentina

The frequency of laparoscopic cholecystectomies in Argentina has increased in the last few years. The use of intraoperative methods for the detection of bile ducts such as intraoperative cholangiography (IOC) varies within the country although it is a routine procedure in our workplace. Surgical injuries in bile ducts remain a constant, amounting to about 0.4%. This is the reason why we have been looking for an easy alternative to IOC, with the aim to reduce those numbers. Sponsored by the company Karl Storz, in 2011 we started performing fluorescence cholangiography in our laparoscopic cholecystectomies; we have kept those records prospectively and now have a total of 65 cases. The use of this method seems promising with some clear advantages such as its low cost, real-time performance and the possibility to visualize structures before they are sectioned. We have been able to visualize the main bile duct without dissection in 89.5% of the cases. Areas that still need improvement include some technical issues such as the depth for visualization in obese patients or in those with severe or substantially chronic inflammatory stages where the light cannot penetrate tissues appropriately.

Ghrelin-Producing Cells in Stomachs: Implications for Weight Reduction Surgery

Ghrelin hormone is a 28-amino acid peptide hormone produced mainly in the mucosa of the stomach. It has an essential role in obesity and metabolic syndrome modifications after bariatric surgery. Changes in the neuro–hormonal axis following sleeve gastrectomy and gastric bypass have been extensively reported. Interestingly, the changes in ghrelin levels after bariatric surgery have varied with different authors’ reports. This may be due to the unclear relationship between the hormones, their receptors, and the central nervous system. Understanding the regulation of ghrelin, the ligand receptor binding activities, the intracellular signaling, and its biological functions could allow surgeons to improve the treatment of morbidly obese patients.

Midgut volvulus as initial presentation of pneumatosis cystoides intestinalis.

Pneumatosis cystoides intestinalis (PCI) is a rare disease with unknown aetiology. It is characterized by the presence of gas-filled cysts within the submucosa or subserosa of the intestine; however, it can be located in any part of the intestinal tract. The pathogenesis, although unknown, seems to be related to the mucosal breakdown and bacterial fermentation. PCI is associated with a variety of diseases in which there is loss of bowel mucosal integrity and/or increased intraluminal pressure. PCI is usually incidentally discovered during diagnostic modalities being carried out for other reasons. In approximately 16% of cases, PCI presents as intestinal obstruction or perforation. Patients commonly present with non-specific gastrointestinal symptoms such as intermittent abdominal pain, nausea, and in cases with colonic involvement, diarrhoea, mucus discharge, rectal bleeding and constipation. Although previously PCI was thought to occur more frequently in the small intestine, more recent studies have shown that PCI appears more frequently in the colon (61.8%), followed by the small intestine (15.4%). A 72-year-old woman presented to the emergency department with a 3-week history of severe back pain with radiation to the abdomen and now recent onset of vomiting. On examination, the vital signs were normal and the abdomen was soft with only minimal tenderness without any peritoneal signs. Laboratory values were also within normal limits. An initial computed tomography (CT) scan without contrast was read as free intra-abdominal air under the right hemidiaphragm (Fig. 1). Because of the overall paucity of clinical signs, a CT with contrast was obtained. The CT scan with oral contrast revealed a large duodenum diverticulum in the right upper quadrant and suggested a possible internal hernia; small pockets of free air were again visualized (Fig. 2). At this point, the patient was taken to the operating room for diagnostic laparoscopy. During laparoscopic exploration, at a distance of about 40 cm from the ligament of Treitz, the small bowel was twisting on itself going under the superior mesenteric artery. The internal hernia was reduced by gentle traction. Once this was accomplished, it became evident that a segment of bowel that was folding on itself contained multiple diverticula. There was no evidence of inflammatory changes, but there appeared to be air under the layer of visceral peritoneum. Since those diverticula had functioned as a lead point for the torsion, the segment of bowel was resected (35 cm) (Fig. 3) with a linear stapler. A standard side-to-side functional end-to-end anastomosis was performed. She was discharged home on postoperative day 4 tolerating regular diet. The pathology report revealed the following: small bowel segment with diverticular disease and serosal adhesions. Histological changes were consistent with arteriovascular malformation and severe atherosclerosis. Seven reactive lymph nodes were negative for neoplasm. In this unusual case report, the clinical presentation was of a volvulus around the superior mesenteric artery, likely secondary to the bulky PCI in the jejunum. To our knowledge, this is the first description of such a presentation of PCI. This underlies the importance of a complete clinical evaluation that does not only take into account the radiological findings. The initial CT scan in our case

Clinical impact of NIR guided surgery(Conference Presentation)

The abstract is not available