John McMichael

Minimally invasive duodenojejunostomy for superior mesenteric artery syndrome: a case series and review of the literature

AbstractBackgroundSuperior mesenteric artery syndrome (SMAS) is a disorder characterized by vascular compression of the duodenum leading to mechanical obstruction. Surgical intervention is indicated in patients who fail standard non-operative management, in which duodenojejunostomy is favored based on previous small series. Given the rarity of the condition, knowledge of the optimal indications for surgery, risk of postoperative complications, and prognosis of SMAS after minimally invasive duodenojejunostomy is limited.MethodsA retrospective chart review was performed on patients who underwent minimally invasive duodenojejunostomy for SMAS from March 2005 to December 2013 at our “healthcare system”. We analyzed patients’ presentations, work-up, surgical therapy, and outcomes.ResultsA series of 14 patients with SMAS underwent minimally invasive duodenojejunostomy. All of these patients met clinical criteria of SMAS with radiological confirmation. Average weight loss before surgery was 10.7xa0kg. Depression and eating disorders were comorbid in 6/14 patients. The mean age was 39xa0years (19–91xa0years). Twelve operations were completed laparoscopically and two were performed with robotic assistance. Mean operation duration was 119xa0min and average length of hospital stay was 5.5xa0days. There were no immediate postoperative complications. One patient developed a delayedxa0anastomotic stricture that improved with single endoscopic balloon dilation. Initial symptom improvement occurred in all patients and the improvement occurred in 11 patients (79xa0%) during the follow-up. At a mean follow-up of 20xa0months, two patients experienced complications, including one infectionxa0at a simultaneously placed J-tube site and one patient with dumping syndrome. Mean weight gain was 3.8xa0kg (pxa0<xa00.01).ConclusionSMAS should be considered a potential diagnosis in patients who present with a history of persistent postprandial vomiting, epigastric pain, and weight loss and confirmatory radiographic findings. In well-selected patients, minimally invasive duodenojejunostomy is a safe and effective treatment for SMAS with excellent short-term outcomes.n

Surgical treatment of medically refractory gastroparesis in the morbidly obese.

IntroductionSurgical management of medically refractory gastroparesis remains a challenge. Case series and small retrospective studies describe clinical benefits from surgical intervention; however, no study reports the efficacy of gastric electrical stimulation (GES) or Roux-en-Y gastrojejunostomy with or without near-total gastrectomy (RYGJ) in morbidly obese patients with severe gastroparesis.MethodsA chart review was performed on all morbidly obese patients (BMIxa0>xa035xa0kg/m2) who underwent GES or RYGJ for medically refractory gastroparesis from March 2002 to December 2012 at the Cleveland Clinic. The main outcomes examined were symptom improvement, postoperative complications, and change in BMI.ResultsA total of 20 morbidly obese patients underwent GES placement. Seven morbidly obese patients had RYGJ with or without resection of the remnant stomach surgery. All operations were completed laparoscopically. In GES group, 18 patients had initial symptom improvement (90xa0%) and 11 (55xa0%) rated their symptom improved at the last follow-up. During the average 23xa0months’ follow-up, 9 patients (45xa0%) experienced at least one readmission for gastrointestinal reasons. Early complications included two infections at a simultaneously placed J-tube site and one seroma. In the RYGJ group, all patients, including 4 patients who failed GES and subsequently converted to RYGJ, experienced short-term symptom improvement and 5 patients (71xa0%) rated their symptoms as improved at last follow-up. One duodenal stump leak happened in the RYGJ group. There were no 30-day mortalities in either group. The BMI change after GES implantation was 0.6xa0±xa04xa0kg/m2 versus −7.7xa0±xa04xa0kg/m2 after RYGJ (pxa0<xa00.01).ConclusionGES implantation and RYGJ are both effective in terms of symptom control for medically refractory gastroparesis in morbidly obese. Both options can be performed in a minimally invasive fashion with low morbidity. Patients who have no improvement of symptoms for refractory gastroparesis after GES implantation can be successfully converted laparoscopically to RYGJ.

Percutaneous Endoscopic Gastrostomy for Decompression of Nonmalignant Gastrointestinal Disease

INTRODUCTIONnThe utility of percutaneous endoscopic gastrostomy (PEG) decompression for inoperable malignant bowel obstruction is well documented. However, there are limited data on decompressive PEG for prolonged ileus, gut dysmotility, and/or complicated nonmalignant bowel obstruction. The aim of this study was to assess the safety and short-term outcomes of decompressive PEG for nonmalignant indications.nnnSUBJECTS AND METHODSnAfter Institutional Review Board approval, we retrospectively reviewed and analyzed all PEG insertions completed at our institution between 2009 and 2014 for prolonged ileus, gut dysmotility, or nonmalignant obstruction.nnnRESULTSnWe identified 72 patients (42 females, 30 males; mean age, 58.8u2009±u200915.2 years) who underwent decompressive PEG for nonmalignant indications. There were no procedural complications or mortalities. The mean pre- and postprocedural length of stays were 14.4u2009±u200910.7 and 7.6u2009±u200911.1 days, respectively (Pu2009=u2009.0003). The 30-day re-admission rate was 12.5% (9 patients; the majority for unrelated issues). Fifty-two (72%) of the 72 patients were discharged with a PEG for decompression for a median of 69.5 (range, 17-316) days; the remaining 20 (28%) patients were lost to follow-up and were assumed to continue follow-up with their primary referring center. Of the 72 patients, 63 (87.5%) were discharged on total parenteral nutrition (TPN); 36 (50%) of those continued to receive TPN for a median of 51 (range, 4-316) days after discharge, and resolution of their mechanical obstruction was ultimately achieved, so that they subsequently resumed enteral nutrition. Twenty-four (33%) patients were lost to follow-up; because they were referred to our tertiary referral center, we assumed they continued follow-up at their referring institution. Three (4%) patients ultimately went on to use TPN indefinitely and thus were considered to be chronically TPN-dependent.nnnCONCLUSIONSnDecompressive PEG insertion is safe and effective at alleviating obstructive symptoms in patients with prolonged postoperative ileus, gut dysmotility, and/or complicated nonmalignant obstruction.

Common bile duct dilation after bariatric surgery

BackgroundBiliary dilation suggests obstruction and prompts further work up. Our experience with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in the symptomatic post-bariatric surgery population revealed many patients with radiographically dilated bile ducts, but endoscopically normal studies. It is unclear if this finding is phenomenological or an effect of surgery. Additionally, it is unknown whether the type of bariatric surgery alters biliary pathophysiology. Thus, we studied whether a change occurs in biliary diameter following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).MethodsA single-center retrospective study assessing biliary diameter before and after RYGB or SG based on radiographic imaging. All adult patients undergoing RYGB or SG from January 2010 to December 2013 who had imaging studies before and >u20093xa0months after surgery were included. Those with known obstructive etiologies and those without post-operative imaging were excluded. Common bile duct (CBD) diameter was re-read by a radiologist at the same location in the CBD for pre- and post-operative imaging. Baseline clinical factors and cholecystectomy status were collected.Results269 patients met inclusion criteria (193 RYGB;76 SG). Between the groups, there were no significant differences in pre-operative characteristics. Average time from surgery to repeat imaging was 24.1xa0months. After adjusting for pre-operative factors, subjects who underwent an RYGB had an increase in CBD diameter of 1.4xa0mm (95% CI 0.096, 0.18), which was greater than the change following SG 0.5xa0mm(95% CI −u20090.007, 0.11). The magnitude of this change did not depend on prior cholecystectomy in the RYGB cohort. Within the SG group, for patients without a prior cholecystectomy, there was a significant increase in post-operative CBD diameter of 0.8xa0mm(95% CI 0.02, 0.14).ConclusionBariatric surgery results in CBD dilation, with changes more pronounced after RYGB. Biliary dilation occurs irrespective of cholecystectomy status. Further work is necessary to determine the cause and clinical implications of this phenomenon.