Hung S. Ho

A comparison study of laparoscopic versus open gastric bypass for morbid obesity

BACKGROUND Laparoscopic Roux-en-Y gastric bypass (GBP) has been previously described, but a comparative study between laparoscopic and open GBP has not been reported. The purpose of this study was to compare surgical outcomes oflaparoscopic GBP with those of open GBP for treatment of morbid obesity. STUDY DESIGN From August 1998 to September 1999, we prospectively collected outcome data on 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent laparoscopic GBP. Demographics, operative data, perioperative complications, and weight losses were collected and compared with those obtained from a retrospective chart review of 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent open GBP before August 1998. RESULTS Age, gender, preoperative body-mass index, preoperative comorbidity, and earlier abdominal surgery were similar in both groups. All laparoscopic operations were completed without conversion to laparotomy. Mean operative time, operative blood loss, length of intensive care stay, and length of hospital stay were significantly less after laparoscopic GBP than after open GBP (p<0.05). There was no 30-day mortality in either group. At 1-year followup, analysis of the percentage of excess body weight loss showed no significant difference between the two groups (p<0.05). CONCLUSIONS Laparoscopic Roux-en-Y gastric bypass is technically feasible and safe. Laparoscopic GBP confers the clinical benefits of laparoscopy and an initial weight loss similar to that of open GBP.

Morbidity, mortality, and technical factors of distal pancreatectomy.

BACKGROUND Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. METHODS Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. RESULTS Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. CONCLUSIONS Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

Effect of Intravascular Volume Expansion on Renal Function During Prolonged CO2 Pneumoperitoneum

OBJECTIVE To evaluate whether intravascular volume expansion would improve renal blood flow and function during prolonged CO2 pneumoperitoneum. SUMMARY BACKGROUND DATA Although laparoscopic living donor nephrectomies have a considerably reduced risk of complications for the donors, significant concerns exist regarding procurement of a kidney in the altered physiologic environment of CO2 pneumoperitoneum. Recent studies have documented adverse effects of CO2 pneumoperitoneum on renal hemodynamics. METHODS Renal and systemic hemodynamics and renal histology were studied in a porcine CO2 pneumoperitoneum model. After placement of a pulmonary artery catheter, carotid arterial line, Foley catheter, and renal artery ultrasonic flow probe, CO2 pneumoperitoneum (15 mmHg) was maintained for 4 hours. Pigs were randomized into three intravascular fluid protocol groups: euvolemic (3 mLkg/hour isotonic crystalloid), hypervolemic (15 mL/kg/hour isotonic crystalloid), or hypertonic (3 mL/kg/hour isotonic crystalloid plus 1.2 mL/kg/hour 7.5% NaCl). RESULTS In the euvolemic group, prolonged CO2 pneumoperitoneum caused decreased renal blood flow, oliguria, and impaired creatinine clearance. Both isotonic and hypertonic volume expansions reversed the changes in renal blood flow and urine output, but impaired creatinine clearance persisted. CONCLUSIONS Intravascular volume expansion alleviates the effects of CO2 pneumoperitoneum on renal hemodynamics in a porcine model. Hypertonic saline (7.5% NaCl) solution may maximize renal blood flow in prolonged pneumoperitoneum, but it does not completely prevent renal dysfunction in this setting. This study suggests that routine intraoperative volume expansion is important during laparoscopic live donor nephrectomy.

Systemic stress response after laparoscopic and open gastric bypass

BACKGROUND The magnitude of the systemic stress response is proportional to the degree of operative trauma. We hypothesized that laparoscopic gastric bypass (GBP) is associated with reduced operative trauma compared with open GBP, resulting in a lower systemic stress response. STUDY DESIGN Forty-eight patients with a body mass index of 40 to 60 were randomly assigned to laparoscopic (n = 26) or open (n = 22) GBP Blood samples were measured at baseline and at 1, 24, 48, and 72 hours postoperatively. Metabolic (insulin, glucose, epinephrine, norepinephrine, dopamine, ACTH, cortisol), acute phase (C-reactive protein), and cytokine (interleukin [IL]-6, IL-8, tumor necrosis factor [TNF]-alpha) responses were measured. Catabolic response was also measured by calculating the nitrogen balance at 24 and 48 hours postoperatively. RESULTS The two groups of patients were similar in terms of age, gender, and preoperative body mass index. The mean operative time was longer for laparoscopic GBP than for open GBP (229 +/- 50 versus 207 43 minutes). After laparoscopic and open GBP, plasma concentrations of insulin, glucose, epinephrine, dopamine, and cortisol increased; IL-8 and TNF-alpha remained unchanged; and negative nitrogen balances occurred at 24 and 48 hours. There was no significant difference in these parameters between groups. Concentrations of norepinephrine, ACTH, C-reactive protein, and IL-6 levels also increased, but these levels were significantly lower after laparoscopic GBP than after open GBP (p < 0.05). CONCLUSIONS Systemic stress response after laparoscopic GBP is similar to that after open GBP, except that concentrations of norepinephrine, ACTH, C-reactive protein, and IL-6 are lower after laparoscopic than after open GBP. These findings may suggest a lower degree of operative injury after laparoscopic GBP.

Women Surgeons in the New Millennium

BACKGROUND Women are increasingly entering the surgical profession. OBJECTIVE To assess professional and personal/family life situations, perceptions, and challenges for women vs men surgeons. DESIGN National survey of American Board of Surgery-certified surgeons. PARTICIPANTS A questionnaire was mailed to all women and men surgeons who were board certified in 1988, 1992, 1996, 2000, or 2004. Of 3507 surgeons, 895 (25.5%) responded. Among these, 178 (20.3%) were women and 698 (79.7%) were men. RESULTS Most women and men surgeons would choose their profession again (women, 82.5%; men, 77.5%; P = .15). On multivariate analysis, men surgeons (odds ratio [OR], 2.5) and surgeons of a younger generation (certified in 2000 or 2004; OR, 1.3) were less likely to favor part-time work opportunities for surgeons. Most of the surgeons were married (75.6% of women vs 91.7% of men, P < .001). On multivariate analysis, women surgeons (OR, 5.0) and surgeons of a younger generation (OR, 1.9) were less likely to have children. More women than men surgeons had their first child later in life, while already in surgical practice (62.4% vs 32.0%, P < .001). The spouse was the offsprings primary caretaker for 26.9% of women surgeons vs 79.4% of men surgeons (P < .001). More women surgeons than men surgeons thought that maternity leave was important (67.8% vs 30.8%, P < .001) and that child care should be available at work (86.5% vs 69.7%, P < .001). CONCLUSIONS Women considering a surgical career should be aware that most women surgeons would choose their profession again. Strategies to maximize recruitment and retention of women surgeons should include serious consideration of alternative work schedules and optimization of maternity leave and child care opportunities.

Cardiac function during laparoscopic vs open gastric bypass

BACKGROUND Hypercarbia and increased intraabdominal pressure during prolonged pneumoperitoneum can adversely affect cardiac function. This study compared the intraoperative hemodynamics of morbidly obese patients during laparoscopic and open gastric bypass (GBP). METHODS Fifty-one patients with a body mass index (BMI) of 40-60 kg/m2 were randomly allocated to undergo laparoscopic (n = 25) or open (n = 26) GBP. Cardiac output (CO), mean pulmonary artery pressure (MPAP), pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), heart rate (HR), and mean arterial pressure (MAP) were recorded at baseline, intraoperatively at 30-min intervals, and in the recovery room. Systemic vascular resistance (SVR) and stroke volume (SV) were also calculated. RESULTS The two groups were similar in terms of age, weight, and BMI. Operative time was longer in the laparoscopic than in the open group (p < 0.05). The HR and MAP increased significantly from baseline intraoperatively, but there was no significant difference between the two groups. In the laparoscopic group, CO was unchanged after insufflation, but it increased by 5.3% at 2.5 h compared to baseline and by 43% compared to baseline in the recovery room. In contrast, during open GBP, CO increased significantly by 25% after surgical incision and remained elevated throughout the operation. CO was higher during open GBP than during laparoscopic GBP at 0.5 h and at 1 h after surgical incision (p < 0.05). During laparoscopic GBP, CVP, MPAP, and SVR increased transiently and PAWP remained unchanged. During open GBP, CVP, MPAP, and PAWP decreased transiently and SVR remained unchanged. There was no significant difference in the amount of intraoperative fluid administered during laparoscopic (5.5 +/- 1.6 L) and open (5.6 +/- 1.7 L) GBP. CONCLUSION Prolonged pneumoperitoneum during laparoscopic gastric bypass does not impair cardiac function and is well tolerated by morbidly obese patients.

Effects of pneumoperitoneum on intraoperative pulmonary mechanics and gas exchange during laparoscopic gastric bypass

Background: Hypercarbia and elevated intraabdominal pressure resulting from carbon dioxide (CO2) pneumoperitoneum can adversely affect respiratory mechanics. This study examined the changes in mechanical ventilation, CO2 homeostasis, and pulmonary gas exchange in morbidly obese patients undergoing a laparoscopic or open gastric bypass (GBP) procedure. Methods: In this study, 58 patients with a body mass index (BMI) of 40 to 60 kg/m2 were randomly allocated to laparoscopic (n = 31) or open (n = 27) GBP. Minute ventilation was adjusted to maintain a low normal arterial partial pressure of CO2 (PaCO2), low normal end-tidal partial pressure of CO2 (ETCO2), and low airway pressure. Respiratory compliance, ETCO2, peak inspiratory pressure (PIP), total exhaled CO2 per minute (VCO2), and pulse oximetry (SO2) were measured at 30-min intervals. The acid–base balance was determined by arterial blood gas analysis at 1-h intervals. The pulmonary gas exchange was evaluated by calculation of the alveolar dead space–to–tidal volume ratio (VDalv/VT) and alveolar–arterial oxygen gradient (PAO2–PaO2). Results: The two groups were similar in age, gender, and BMI. As compared with open GBP, laparoscopic GBP resulted in higher ETCO2, PIP, and VCO2, and a lower respiratory compliance. Arterial blood gas analysis demonstrated higher PaCO2 and lower pH during laparoscopic GBP than during open GBP (p < 0.05). The VDalv/VT ratio and PAO2–PaO2 gradient did not change significantly during laparoscopic GBP. Intraoperative oxygen desaturation (SO2 < 90%) did not develop in any of the patients in either group. Conclusions: Laparoscopic GBP alters intraoperative pulmonary mechanics and acid–base balance but does not significantly affect pulmonary oxygen exchange. Changes in pulmonary mechanics are well tolerated in morbidly obese patients when proper ventilator adjustments are maintained.

Gastrostomy for enteral access : A comparison among placement by laparotomy, laparoscopy, and endoscopy

AbstractBackground: Access to the stomach for long-term enteral feeding can be achieved via laparotomy (open GT), laparoscopy (lap GT) or endoscopy (PEG). We compared the three methods of gastrostomy to determine whether any one has an advantage over the others. Methods: A retrospective analysis was done of 356 gastrostomies performed between January 1990 and June 1995. Results: Of these 356 gastrostomies, 214 were open GT, 60 were lap GT, and 82 were PEG. The completion rate was high, 98.1% to 100%. The perioperative mortality rates were low and similar among the 3 methods; 4.2% for open GT, 5.3% for lap GT, and 4.9% for PEG (p= 0.87, Chi square test). Cardiac arrest was the predominant immediate cause of all perioperative deaths (68.8%). Overall, none of the deaths was directly related to the gastrostomy procedure. Major complications occurred in 24.9% of patients receiving open GT, in 18.3% of patients with lap GT, and in 17.1% of patients with PEG. Long-term complications developed in 25.9% of open GT, 25.6% of lap GT, and 30.4% of PEG. The revision rates were similar for all 3 methods, 6.7% for open GT, 10% for lap GT, and 6.1% for PEG. Conclusions: Gastrostomy can be performed safely by all three techniques, with similar outcomes. PEG is our method of choice. Lap GT is preferred in patients with head and neck carcinoma, patients with obstructing esophageal carcinoma, and patients who have problems with overlying liver or colon. Open GT is reserved for cases with extensive intraabdominal adhesions or those where the procedure is done during an ongoing laparotomy.

Cardiopulmonary responses to intravenous infusion of soluble and relatively insoluble gases

AbstractBackground: Carbon dioxide is the current gas of choice for pneumoperitoneum, but hemodynamic and acid–base effects secondary to its systemic absorption have been reported. Various studies have suggested inert gases as alternatives. Methods: We studied the cardiopulmonary responses to intravenous infusion of carbon dioxide, nitrous oxide, argon, helium, and nitrogen in anesthetized swine. The gas was infused into the femoral vein at a rate of 0.1 ml · kg−1· min−1 for 30 min. The changes in end-tidal CO2, mean arterial pressure, hemodynamics, and arterial blood gases were compared to baseline values. Results: No animals died during infusion of the soluble gases (CO2 and N2O). Three of the five pigs infused with nitrogen died suddenly at 20 and 30 min of infusion. The animals in the insoluble gas groups (Ar, He, N2) experienced clinical pulmonary gas embolism and severe acidemia, hypercapnea and tachycardia. Conclusions: Venous gas embolism is poorly tolerated when the gas is relatively insoluble. Insoluble gases should not be used for pneumoperitoneum when there is any risk of venous gas embolism.

Laparoscopic Roux-en-Y gastric bypass for super/super obesity.

Laparoscopic gastric bypass has been recently introduced as an alternative method to conventional open gastric bypass. This procedure has been generally limited to patients with a BMI <60 kg/m2 due to the possible technical limitations of the laparoscopic instruments. In this article, we present a patient with super/super obesity (61 kg/m2) who underwent Rouxen-Y gastric bypass using the laparoscopic approach.