Haris A. Khwaja

Petersen hernia complicating laparoscopic duodenal switch

l p t b Petersen type hernias have become increasingly recognized with the worldwide adoption of laparoscopic gastric bypass. So-called Petersen’s hernia (PH) is contemporarily defined as an internal hernia through the space between the mesentery of the alimentary limb and the transverse mesocolon. PH can be classified by type and symptoms [1]. No level I data are available to inform surgeons whether Petersen’s space should be closed at primary surgery, and this has led to a lively debate in published studies [2–6]. However, it is clear that PH can present nonspecifically, is diagnostically challenging, and can rapidly cause fatal complications. Our unit policy is to close Petersen’s space at gastric bypass. Similar to gastric bypass, Petersen’s space is created during laparoscopic biliopancreatic diversion and duodenal switch (BPD/DS) procedure (Fig. 1). A paucity of data is available regarding PH and laparoscopic BPD/DS. We present 4 cases of symptomatic PH complicating laparoscopic BPD/DS (Table 1).

Subcutaneous emphysema in a case of infective sinusitis: a case report

IntroductionSubcutaneous emphysema with pneumomediastinum is a rare phenomenon with a high morbidity and may occur spontaneously.Case presentationA 30-year-old Caucasian man presented with sudden onset of a painful, swollen neck and was found, via clinical and radiological examination to have subcutaneous emphysema. A swallow study showed no oesophageal perforation. Computed tomography of his neck and thorax demonstrated pneumomediastinum but no other pathology. Management was conservative with intravenous antibiotics, fluids and no oral intake. He had a history of a productive cough and a flexible nasoendoscopy found purulent sinusitis which was treated with topical nasal washes. The patient was discharged after 72 hours and will be followed up by the otolaryngology-head and neck service.ConclusionsInfective sinusitis is a rare cause of subcutaneous emphysema and pneumomediastinum. It may be managed conservatively provided there is early recognition and exclusion of more serious pathology, such as a ruptured trachea or oesophagus.

Endometriosis: a rare cause of small bowel obstruction

Although endometriosis is a common condition in young women, symptomatic involvement of the small bowel is rare. The authors report the case of a 44-year-old lady initially thought to have irritable bowel syndrome who presented 1 month later with acute small bowel obstruction. A CT scan showed small bowel dilatation with a transition point in the ileum, but no distinct lesion. The patient had an exploratory laparotomy where an obstructing lesion in the terminal ileum and several enlarged mesenteric lymph nodes were identified. Consequently, a right hemicolectomy was performed. Pathology specimens showed multiple endometriotic foci in the bowel with stricturing of terminal ileum and appendiceal intussusception. This likely resulted in subocclusive episodes and intestinal obstruction. This case highlights the difficulty in establishing a preoperative diagnosis of endometriosis. Small bowel endometriosis should, therefore, be considered in the differential diagnosis of women of childbearing age who present with symptoms of obstruction.

The International Bariatric Club – A Worldwide Web Educational Network for Bariatric Professionals

The International Bariatric Club (IBC) is a free, non-profitmaking organization open to all bariatric surgery/medicine professionals with the primary aim of education. The IBC is easily accessible through a dedicated website (www.ibcclub.org) which was launched in March 2012. The IBC was conceived by Tomasz Rogula, Assistant Professor of Surgery and Philip Schauer, Professor of Surgery from the Cleveland Clinic Foundation, USA in 2008. Initially, the club consisted simply of amonthly seminar broadcast over the internet with the help of WebEx (web conferencing), based at the Cleveland Clinic campuses in Ohio and Florida. These 1-hour talks were built within the curricula of the Fellowship in Advanced Laparoscopy/Bariatric Surgery of both institutions. The combined, monthly webinar was established to consolidate the Cleveland Clinic Foundation Fellowship education program. Fellows would present a concise review of 1–2 recently published bariatric papers from reputable journals. These webinars initially attracted a small on-line audience and allowed questions to be put to the speaker regarding the presentation from on-line attendees. The aims of the IBC are summarized in Table 1.

Necrotising fasciitis of the lower limb due to diverticular disease of the sigmoid colon

Dear Editor: Necrotising fasciitis is a rare, aggressive soft tissue infection which most often occurs after local injury to the skin. It may be caused by either a mixture of aerobic and anaerobic bacteria, or purely anaerobic species, and is associated with bacteraemia in many cases. Rarely, there may be no breach of skin integrity, and infection may have been seeded from another site in the body. We describe a case in which the patient presented with necrotising fasciitis of the left anterior thigh without any abdominal symptoms or findings. The origin of this infection was subsequently found to be a perforated sigmoid colon due to diverticular disease. Both local debridement of the soft tissues of the limb and definitive surgical management of the abdominal pathology were needed. A 78-year-old woman was referred as an emergency to the surgical team complaining of a 2-week history of dull left thigh and leg pain. This had become severe over the preceding 5 days with difficulty in weight bearing for 24 h. There was no history of trauma. Her past medical history included polymyalgia rheumatica, for which she was taking prednisolone 5 mg once daily, mild rheumatoid arthritis and osteoporosis. She was pyrexial (37.8°C), tachypnoeic and tachycardic. Abdominal and rectal examinations were normal. Examination of the left lower limb revealed significant oedema and erythema arising from just below the inguinal ligament extending to below the mid thigh. The skin was warm and there was crepitus. The patient was unable to move the left leg actively, and passive movements at the left hip joint were restricted due to severe pain. X-rays of the pelvis were normal, but an X-ray of the left thigh revealed extensive gas within the muscle planes of the left anterolateral compartment. Chest and abdominal X-rays were normal. A diagnosis of necrotising fasciitis was made. Blood tests showed a Hb 8.7 g/dL, WCC 28.3 (24.6 neutophilia), platelets 831, CRP of 322, normal renal function and clotting screen. Arterial blood gases on air were normal. The patient was resuscitated with oxygen, intravenous fluid therapy, empirical treatment with IV cefotaxime (2 g tds), metronidazole (500 mg tds), vancomycin (1 g bd) and gentamicin (120 mg stat and 80 mg bd) and was taken to the theatre immediately. An anterolateral incision from the tip of the greater trochanter to the knee was made, revealing gross oedema in the subcutaneous plane with large amounts of necrotic fat. There was a large amount of gas deep to the tensor fascia lata with foul-smelling necrotic fat and a large amount of thin pus. The thigh muscles were viable. The pus and necrotic fat were sent for an urgent gram stain, and an extensive debridement was done of all nonviable tissues. A counter incision was made in the anterior thigh to drain a further collection of pus. The wound was irrigated with saline and the wound dressed with gauze. H. A. Khwaja Department of Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA

Bifurcated Dacron patch for simultaneous superficial femoroplasty and profundoplasty: a case report

IntroductionCommon femoral endarterectomy and/or profundoplasty are procedures commonly performed on patients with functional or critical limb ischaemia.Case presentationA 61-year-old Caucasian British man was referred to our unit with recent onset of severe left calf and thigh claudication and rest pain in his left foot. Magnetic resonance angiography revealed occlusive disease of the left common femoral artery, proximal superficial and profunda femoral arteries.These findings were confirmed intraoperatively and an endarterectomy was subsequently performed from the left common femoral onto the proximal superficial femoral artery and then onto the proximal profunda femoris artery. The arteriotomy was closed with a Dacron patch and its distal end was bisected into two to patch the profunda femoris and superficial femoral arteries. The patient made an uneventful recovery with a full clinical improvement of his left leg.ConclusionA Dacron patch that was bisected distally to make a bifurcated patch for simultaneous patching of the profunda femoris artery and the superficial femoral artery was used to treat our patients occlusions. This technique has not been previously described in the published literature and we have found it easy to do with little time added to conventional operation.

Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD-DS) Surgery

Biliopancreatic diversion with duodenal switch (BPD-DS) produces unmatched weight loss and superb resolution of comorbidities, particularly type 2 diabetes; however BPD-DS remains a controversial procedure that polarises opinion in both surgeons and patients. It combines surgical bypass of the majority of the small intestine with a sleeve gastrectomy in an attempt to produce greater weight loss and improved remission of comorbidities compared to that seen after Roux-en-Y gastric bypass (RYGB), whilst reducing the incidence of common side effects of a standard BPD such as marginal ulceration and dumping syndrome. With careful patient selection, meticulous technique and attentive follow-up, BPD-DS offers patients outstanding long-term clinical results, a surprisingly good quality of life and an effective revisional option when other procedures have failed. Done badly, it is a recipe for protein-calorie malabsorption and a return to the bad old days of bariatric surgery from the 1970s. In this chapter we explore the essentials of how to use this powerful tool- the nuclear option in the bariatric surgeon’s armamentarium- safely and effectively.

Evidence Base for Bariatric Surgery

Bariatric surgery is recognized worldwide as a cost-effective treatment for morbidly obese patients. In recent years, the role of these procedures has been revised following the impressive postoperative outcomes from a metabolic and functional viewpoint. These outcomes have given rise to further possible indications for bariatric procedures that could be applied to non-obese patients in the near future. This chapter summarizes the evidence collected following bariatric procedures, both in terms of weight loss and remission of co-morbidities. We still need to clarify the concepts of “ideal weight” and “success” in bariatric surgery and moreover the exact interaction between gut hormones, pancreatic endocrine function and adipose cell signaling needs further investigations to predict a possible outcome or a possible relapse of a metabolic condition.

Gallbladder agenesis with midgut malrotation

A 28-year-old female presented with a 4 year history of intermittent right upper quadrant pain. Clinical examination and ultrasound suggested a diagnosis of cholelithiasis and the patient was eventually booked for a laparoscopic cholecystectomy. Intraoperatively the patient was found to have gallbladder agenesis and small bowel malrotation with the duodenojejunal flexure to right of midline. The gallbladder fossa was filled with fibrous tissue. Both gallbladder agenesis and midgut malrotation are rare congenital abnormalities. Gallbladder agenesis has a similar presentation to more common gallbladder pathologies, such as cholecystitis. This case illustrates the limitations of and our over reliance on radiological imaging. Moreover, it highlights the need to have a high index suspicion of gallbladder agenesis when ultrasound is inconclusive. Further investigations and imaging with modalities such as MRI should be used to reduce the risks associated with unnecessary surgical intervention.