Fred Brody

Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

BACKGROUNDnDespite the proliferation of laparoscopic Roux-en-Y gastric bypass (LRYGBP), postoperative bowel obstructions still occur from mesocolonic constrictions, internal hernias, and anastomotic strictures. Obstructed patients do not present with a characteristic history and physical. Therefore, radiographic studies including upper gastrointestinal films and computed tomography are essential for diagnosing these unique obstructive etiologies after LRYGBP.nnnMETHODSnFrom February 2000 to December 2000, 115 patients underwent standard LRYGBP at the Cleveland Clinic Foundation. Retrocolic anastomoses were performed on all patients. Defects at the mesocolon and mesomesentery were closed with interrupted, nonabsorbable sutures. All patients underwent upper gastrointestinal study on the first postoperative day.nnnRESULTSnSix patients developed small bowel obstructions postoperatively. Five of these patients required reexploration. The obstructive etiologies were two mesocolonic constrictions, three internal herniations, and one massive clot at the gastrojejunostomy. Repair of the mesocolonic constrictions involved incising the transverse mesocolon vertically to create a larger window for the Roux limb. Internal herniations were reduced, and defects were reclosed with nonabsorbable sutures. The patient with an obstructive clot was treated endoscopically.nnnCONCLUSIONSnBased on these 6 patients, we have altered our technique to antecolic placement of the Roux limb. This technique requires division of the omentum and additional mobilization of the Roux limb mesentery in order to decrease tension at the gastrojejunostomy. Since initiating these changes and closing all iatrogenic defects, we have not experienced further early small bowel obstructions.

Single Incision Laparoscopic Cholecystectomy

d s t i a m t c w c t c nce the first laparoscopic cholecystectomy (LC) was perormed in 1987, the 4-port laparoscopic technique estabished itself quickly as the standard of care for cholecystecomy. Recently, single incision laparoscopic surgery (SILS), ingle port access surgery (SPA), or laparoendoscopic single ite surgery (LESS), has been used for several procedures ncluding donor nephrectomy, colectomy, sleeve gastrecomy, splenectomy, adrenalectomy, hernia repair, appenectomy, and cholecystectomy. For the general surgeon, ESS has found a niche with cholecystectomy and early eports of LESS cholecystectomy appeared in 1997 and 999. These reports were followed by a multitude of ase reports or small series throughout the literature. Major bstacles of LESS cholecystectomy were identified and inluded poor ergonomics, decreased visualization, and inadquate retraction. All of these obstacles increased the comlexity and difficulty of an operation that was commonly ompleted safely in less than an hour. Presently, the availble literature documents the feasibility of LESS cholecysectomy, and only 1 report compares LESS cholecystecomy with traditional LC. This report describes an initial eries of LESS cholecystectomies to date, and details opertive technique, clinical outcomes, and early (24-hour) ostoperative narcotic usage.

Implantable gastric stimulation for the treatment of clinically severe obesity: results of the SHAPE trial.

BACKGROUNDnTo compare implantable gastric stimulation therapy with a standard diet and behavioral therapy regimen in a group of carefully selected class 2 and 3 obese subjects by evaluating the difference in the percentage of excess weight loss (EWL) between the control and treatment groups. The primary endpoint was the percentage of EWL from baseline to 12 months after randomization. Implantable gastric stimulation has been proposed as a first-line treatment for severely obese patients; however, previous investigations have reported inconclusive results.nnnMETHODSnA total of 190 subjects were enrolled in this prospective, randomized, placebo-controlled, double-blind, multicenter study. All patients underwent implantation with the implantable gastric stimulator and were randomized to 1 of 2 treatment groups: the control group (stimulation off) or treatment group (stimulation on). The patients were evaluated on a monthly basis. All individuals who enrolled in this study agreed to consume a diet with a 500-kcal/d deficit and to participate in monthly support group meetings.nnnRESULTSnThe procedure resulted in no deaths and a low complication rate. The primary endpoint of a difference in weight loss between the treatment and control groups was not met. The control group lost 11.7% +/- 16.9% of excess weight and the treatment group lost 11.8% +/- 17.6% (P = .717) according to an intent-to-treat analysis.nnnCONCLUSIONnImplantable gastric stimulation as a surgical option for the treatment of morbid obesity is a less complex procedure than current bariatric operations. However, the results of the present study do not support its application. Additional research is indicated to understand the physiology and potential benefits of this therapy.

Laparoscopic Versus Single-Incision Cholecystectomy

BackgroundAlthough recent reports demonstrate large series of single-incision cholecystectomies, few articles compare single-incision data with traditional laparoscopic cholecystectomy (LC) data. This article compares a large series of single-incision cholecystectomies to a series of traditional LCs performed at an urban tertiary-care center.MethodsA consecutive series of single-incision cholecystectomies was performed from August 2008 to March 2010. All cholecystectomies were attempted through a single incision on an intent-to-treat basis. Patient demographics, including height, weight, body mass index (BMI), pathologic diagnosis, ASA classification, operative time, complications, narcotic use, and length of stay (LOS), were recorded. Data for a matched cohort of patients undergoing a traditional four-port LC were gathered over a similar time period. Data were compared using a t test with a Pxa0<xa00.05 for significance.ResultsSingle-incision cholecystectomy was successful in 81 (76%) of 107 patients. The 26 (24%) converted cases showed a higher BMI (33.0xa0±xa08.7 vs. 28.4xa0±xa06.4xa0kg/m2, Pxa0<xa00.05) and longer operative times (98.3xa0±xa033 vs. 76.1xa0±xa023xa0min, Pxa0<xa00.003). Postoperatively, the converted patients had a longer LOS compared to that of the single-incision group (1.6xa0±xa01.0 vs. 1.1xa0±xa00.4xa0days, Pxa0=xa00.02). Overall, the single-incision group had longer operative times compared to the four-port LC group (81.5xa0±xa028 vs. 69.1xa0±xa021xa0min, Pxa0<xa00.004). However, after the tenth single-incision case, there was no difference in operative times. From a narcotic standpoint, the successful single-incision patients used significantly less narcotic versus the traditional LC group (20xa0±xa022.7 vs. 32.3xa0±xa031.2xa0mg, Pxa0=xa00.02).ConclusionsThe data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy. Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS. Although this data is intriguing, the overall utility of single-incision procedures requires more analysis and potentially randomized trials.

Analysis of poor outcomes after laparoscopic adjustable gastric banding

BackgroundRecent studies document excess weight loss (EWL) of more than 50% with the laparoscopic adjustable gastric band (LGB). This study reviews the LGB experience at an urban academic center in terms of complications, reoperative rates, and comorbidities.MethodsIn this study, 144 consecutive patients undergoing LGB were prospectively reviewed. Data were collected including weight, body mass index (BMI), excess weight loss (EWL), comorbidities, and complications. Demographics were analyzed using a t-test. Linear regression was used to analyze the relationship of BMI, race, and age to EWL at 12xa0months.ResultsThe study participants were 130 women with a mean age of 43xa0±xa011xa0years, a mean weight of 127.1xa0kgxa0±xa020.5xa0kg, and a mean BMI of 45.6xa0±xa06.1. The mean follow-up period was 16xa0months. The mean EWL was 20%xa0±xa014% at 6xa0months (nxa0=xa0118), 26%xa0±xa016% at 12xa0months (nxa0=xa0106), 30%xa0±xa020% at 18xa0months (nxa0=xa068), and 34%xa0±xa023% at 24xa0months (nxa0=xa043). Patients with a BMI higher than 50xa0kg/m2 had a lower EWL at 12xa0months than patients with a BMI lower than 50xa0kg/m2 (Pxa0=xa00.00005). The mean EWL at 12xa0months was significantly less for African Americans than for Caucasians (Pxa0=xa00.0046; 95% confidence interval [CI] 3–15%). Patients older than 50xa0years had a lower EWL, but the difference was not statistically significant (Pxa0=xa00.07). Complete and partial resolution of comorbidities occurred for 10% and 4% of the patients, respectively. Removal of the band with revision to a sleeve gastrectomy for inadequate EWL was required for 14 patients (11.5%). Complications occurred for 8% of the patients (nxa0=xa015) including port flipping, stoma obstruction, tube disconnection, port infections, dysphagia, and band slippage. Overall, 16.7% of the patients (nxa0=xa024) required reoperation.ConclusionAfter LGB, a majority of the patients failed to achieve a 50% EWL, and 16.7% required reoperation. Laparoscopic adjustable gastric banding may not be the optimal bariatric procedure for patients older than 50xa0years, patients with a BMI higher than 50xa0kg/m2, or African Americans.

Gastric Electrical Stimulation for Gastroparesis

BACKGROUNDnRecently, gastric electrical stimulation (GES) has been used to treat gastroparesis. This study analyzes a cohort of gastroparetic patients after GES.nnnSTUDY DESIGNnAll patients undergoing GES from October 2003 to July 2007 were included. Pre- and postoperative assessments were performed for frequency and severity of gastrointestinal symptoms and gastric retention. The values were compared using a paired t-test for patients at 6 and 12 months. Statistical significance was defined as p < 0.05.nnnRESULTSnFifty gastroparetic patients were enrolled (20 diabetic, 25 idiopathic, 2 postsurgical, and 3 connective tissue disorder patients). All patients underwent laparoscopic implantation with GES (Medtronic, Inc). Median followup was 28 months (range 3 to 51 months). Thirty-five patients were available for followup at 6 months, and 30 patients were available at 12 months. The total symptom severity score (19.05+/-8.04) decreased significantly at 6 months (12.92+/-7.41, p < 0.001) and 12 months (14.05+/-8.28, p < 0.01). Similarly, total frequency score (20.39+/-8.08) decreased significantly at 6 months (15.01+/-7.37, p < 0.01) and 12 months (15.71+/-7.40, p < 0.05). At 12 months (n=27), gastric retention at 2 hours was decreased significantly from 66% +/- 21% to 50% +/- 22% (p < 0.04) and normalized in 11 of 27 patients. The severity of symptoms was reduced in all patients with normal gastric retention postoperatively. Finally, gastric retention at 4 hours was reduced by 14%, but the difference was not significant.nnnCONCLUSIONSnGastroparetic symptoms at 6 months were improved and sustained at 12 months after GES. Gastric emptying at 2 hours was reduced significantly after GES. Longterm followup of this cohort is required to confirm the short-term effects of GES.

Management of splenic abscess in a critically ill patient.

Because of the increased number of immunocompromised patients within the general population, the incidence of splenic abscesses has increased over the last decade. This cohort of immune-deficient patients with splenic abscesses engenders a distinct evolution in the pathogenesis and microbiology of the disease process. Moreover, the morbidity and mortality rates for splenic abscesses are increased in this unique population. Clinically, these patients do not have a characteristic presentation. Diagnostically, computed tomography of the abdomen is the test of choice. Antibiotics and splenectomy remain the standard of care in most clinical settings. However, percutaneous drainage is reported with solitary and unilocular abscesses and in poor operative candidates. An unusual case of a patient with a splenic abscess awaiting heart transplantation is presented. This patient was successfully treated with percutaneous drainage and antibiotics. The literature regarding the presentation, diagnosis, pathogenesis, and treatment of splenic abscesses is reviewed as well.

Laparoscopic Adrenalectomy: A Cost Analysis of Three Approaches

Laparoscopic adrenalectomy (LA) is the current standard for treatment of benign adrenal disease and is performed more often now in the setting of malignant disease. Three surgical approaches, the lateral transperitoneal technique, the lateral retroperitoneal technique, and the posterior technique are utilized commonly. While advantages of each approach are advocated, a cost analysis is not available. This article analyzes the operating costs of the three approaches. The operative costs of 51 unilateral LA at the Cleveland Clinic Foundation from 1998 to 2002 were analyzed for comparison. Patients were grouped according to one of the three laparoscopic approaches--transperitoneal (group A), lateral retroperitoneal (group B), and posterior (group C). For each group, n=17. Perioperative characteristics and operative cost were analyzed. The groups were compared using single factor ANOVA analysis. Significance was assigned for P<0.05. The average costs of unilateral LA were

Dysregulation of gene expression within the peroxisome proliferator activated receptor pathway in morbidly obese patients

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Preoperative Liver Reduction Utilizing a Novel Nutritional Supplement

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