Jeremy Tan

Diagnosis and Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy for Morbid Obesity

BackgroundLaparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. The leak rate from the gastric staple line ranges from 1.4% to 20%. From our experience of management of LSG leaks, we have been able to formulate an algorithm-based approach to the management of these patients.MethodsAll patients referred to our hospital within a 24-month period with a diagnosis of gastric staple line leak in the background of a previous LSG were included in the study. A retrospective case note review was undertaken for these patients and an algorithm formulated.ResultsThere were fourteen patients in the study. There were four males and ten females. Patients were managed with a combination of laparotomy, laparoscopy, endoscopic covered stenting, percutaneous radiologically guided drainage, jejunal enteric feeding and total parenteral nutrition. In five patients, re-look laparoscopy or laparotomy with washout and drainage was performed. The remaining eight patients were managed conservatively. There were no deaths.ConclusionsAlthough it is often disappointing when LSG leaks do occur, with adherence to the basic tenets of the surgical management of enterocutaneous fistulae as well as early detection and a high index of suspicion, these complications can be successfully managed using an algorithm-based multi-disciplinary team approach.

DNA methylation within the I.4 promoter region correlates with CYPl19A1 gene expression in human ex vivo mature omental and subcutaneous adipocytes

BackgroundDNA methylation at specific CpG sites within gene promoter regions is known to regulate transcriptional activity in vitro. In human adipose tissue, basal transcription of the aromatase (CYP19A1) gene is driven primarily by the I.4 promoter however the role of DNA methylation in regulating expression in ex vivo mature adipocytes is unknown. This observational study reports the correlation of DNA methylation within the I.4 promoter region of human mature subcutaneous and omental adipocytes with aromatase expression and body composition measures.MethodsOmental and subcutaneous adipose tissue were collected from 25 obese subjects undergoing bariatric surgery and the mature adipocyte fraction purified. DNA methylation status of 5 CpG sites within a 550 base pair region encompassing the transcription start site (TSS) of promoter I.4 was determined using pyrosequencing. Relative aromatase and I.4 promoter specific mRNA expression was determined by qRT-PCR and whole body DXA performed in 25 participants.ResultsSite-specific DNA methylation varied from 21 ± 10% to 81 ± 11%. In omental adipocytes percentage methylation at the I.4.1 and I.4.2 CpG sites, but not other nearby sites, was negatively correlated with relative aromatase mRNA expression (R = - 0.52, P = 0.017 and R = - 0.52, P = 0.015). In contrast subcutaneous adipocytes percentage DNA methylation at the I.4.3 and I.4.5 sites were positively correlated with relative aromatase mRNA expression (R = 0.47, P = 0.022 and R = 0.55, P = 0.004). In a small subset of patients DNA methylation at the I.4.5 site was also positively correlated with whole body lean mass, bone mineral content and density.ConclusionsIn conclusion in mature adipocytes, the primary source of estradiol after menopause, increasing DNA methylation was correlated with aromatase mRNA expression and thus estradiol biosynthesis. These findings support a tissue-specific epigenetic regulation of the basal promoter activity in mature adipocytes; the mechanisms influencing this regulation and its physiological role remain to be elucidated.

Gyrus PlasmaKinetic bipolar coagulation device for liver resection.

Background:  Liver parenchymal transection can be associated with significant blood loss and morbidity. We present our initial experience with the Gyrus PlasmaKinetic coagulation device in liver parenchymal resection in both cirrhotic and non‐cirrhotic patients.

Tension haemothorax: an uncommon life-threatening complication.

A 42-year-old woman was transferred from a peripheral hospital to the Emergency department of Sir Charles Gairdner Hospital (Perth, Australia) in profound shock. Nine days previously, a bilateral circumareolar reduction mammoplasty had been performed. A right breast haematoma occurred, requiring submammary drainage and placement of surgical drains under direct vision. The patient required transfusion of four units of packed cells as the haemoglobin (Hb) had fallen to 65 g/L. Her previous surgical history (laparoscopic cholecystectomy, three caesarean sections) was unremarkable. Following surgical evacuation, swelling of the right breast persisted. Five days later, the patient complained of acute dyspnoea and of severe right-sided chest pain. The electrocardiogram (ECG) demonstrated sinus tachycardia (ST) and was reported as exhibiting an ‘S1Q3T3’ pattern. The chest X-ray (CXR) revealed opacification of the entire right hemithorax. A clinical diagnosis of pulmonary embolism (PE) was made and the patient was anticoagulated with 65 mg subcutaneously of enoxaparin sodium (Clexane, Aventis Pharma, Lane Cove, Sydney). A helical computed tomography-scan of the thorax revealed a large right-sided pleural effusion consistent with a haemothorax, but no evidence of PE (Fig. 1). Despite an acute Hb fall to 78 g/L, her haemodynamics remained stable. Following the transfusion of fresh frozen plasma (2 units), cryoprecipitate (7 units) and packed cells (2 units), the coagulation screen was normal (platelets: 303 × 109/L; international normalized ratio (INR): 0.9; activated partial thromboplastin time (APTT): 28 s; D-dimer: 0.2 < mg/L). Twelve hours later, acute hypotension and systolic blood pressure (SBP) of 90 mmHg, unresponsive to volume replacement occurred, mandating an emergency transfer to our Accident and Emergency department. On arrival, the patient was in profound shock (SBP: 65/45 mmHg; ST: 150 b.p.m.; jugular venous pulse (JVP): 20 cm). Marked left-sided tracheal deviation was present, air entry and breath sounds were absent over the right hemithorax. Asymmetry of the breasts was noted with marked bruising of the right breast. Immediate insertion of a lateral intercostal tube (ICT) produced a marked haemodynamic improvement. Upon breaching the chest wall, blood gushed at high pressure from within the pleural cavity; approximately 700 mL drained within 5 min. The restoration of normal haemodynamics was immediate (BP: 120/75 mmHg; JVP: normal). A transthoracic echocardiogram CASE REPORT

Leaks in fixed-ring banded sleeve gastrectomies: a management approach

BACKGROUND The use of a Fobi ring to prevent pouch dilation is sometimes used in Roux-en-Y gastric bypass (RYGB). Recently, it has been extrapolated to laparoscopic sleeve gastrectomy (LSG) procedures by placing a fixed-ring band a few centimeters below the gastroesophageal junction (GEJ). OBJECTIVES What is the consequence if a patient develops a leak? SETTING Tertiary metropolitan referral center, Australia. METHODS Over 18 months, all patients with either a conventional LSG or a fixed-ring banded sleeve gastrectomy (BLSG) who presented with a proven leak complication were included. The management approaches along with the surgical, endoscopic, and percutaneous procedures used were examined. RESULTS Six patients had a BLSG leak and 6 had a LSG leak. All patients had leak resolution. There was no significant difference in body mass index (BMI), time to leak, initial white cell count (WCC), and C-reactive protein (CRP) levels between the 2 groups. LSG patients required a median of 2 endoscopic procedures (range: 1-3). Stents were deployed in 3 patients. All BLSG patients required a single surgical intervention with laparoscopic washout, drainage, removal of band±feeding jejunostomy. One stent was deployed in 1 BLSG patient. BLSG leak resolution was found at 34±12 days versus 85±12 days in the LSG group (P< .05). CONCLUSION The BLSG is a new modification of the sleeve gastrectomy procedure. This study presents a management strategy for leak resolution employed in BLSG patients. The presence of a foreign body as a persistent nidus of infection mandates band removal.

Secondary aorto-esophageal fistula managed with endoluminal stenting

omentum. Presentation and symptoms depend on the organ involvement and surgical intervention is often imperative. Mortality can be as high as 80% when gastrointestinal ischaemia occurs, and prompt surgery is therefore required. Abnormality of the diaphragmatic contour on chest radiographs may be present, but early diagnosis with appropriate management can be difficult when the original injury is remote and clinicians do not consider the possibility of this diagnosis. Detailed history combined with careful review of the radiological imaging is required to prevent a delayed diagnosis with resultant mortality and morbidity.

Trans-thoracic peri-oesophageal adjustable band for intractable reflux

Highlights • Laparoscopic adjustable gastric bands improve symptoms of reflux.• Adjustable band placed via trans-thoracic approach due to hostile abdomen.• Peri-oesophageal band for reflux.

HP03 A NOVEL AND SAFE DEVICE FOR HEPATIC PARENCHYMAL TRANSECTION DURING LIVER RESECTION: THE GYRUS PLASMAKINETIC PULSED BIPOLAR COAGULATION FORCEPS

Introduction  The Gyrus PlasmaKinetic bipolar coagulation device has been described for use in most types of abdominal surgery. However, its use in liver resection has, to date, not been described. This study has been conducted to evaluate the safety and efficacy of the Gyrus PlasmaKinetic bipolar coagulation device during the parenchymal transection phase of both open and laparoscopic liver resections.