Karen E. Gibbs

Laparoscopic Roux-en-Y pancreatic cyst-jejunostomy

AbstractBackground: n The surgical management of pancreatic pseudocysts can be established through a variety of techniques. Internal drainage has consistently proven to be the treatment of choice for both acute and chronic pancreatic pseudocysts. With the growing popularity of minimally invasive surgery and improvements in surgical technique, laparoscopic internal drainage procedures for pancreatic pseudocysts are being attempted. While most authors have focused on laparoscopic cyst-gastrostomies, few have written about laparoscopic cyst-jejunostomies. Methods: In this article, we report our experience with eight laparoscopic Roux-en-Y cyst-jejunostomies. Of the eight patients, six had alcoholic pancreatitis, and two had gallstone pancreatitis. There were five men and three women with a mean age of 48 (range 35–71 years). Results: The mean operative time was 150 min, with a range of 100–215 min. We report a mean EBL of 78 cc, a minor complication rate of 20%, and no major complications or mortalities. Conclusions: These data compare favorably with both open and laparoscopic internal drainage procedures. Laparoscopic cyst-jejunostomy offers a feasible alternative in the minimally invasive management of pancreatic pseudocyst.

Intestinal Malrotation in a Patient Undergoing Laparoscopic Gastric Bypass

Intestinal malrotation is an anomalous disorder resulting from the incomplete rotation and fixation of the midgut during embryonic development. Although most patients present early in life with symptoms of bowel obstruction, others remain asymptomatic throughout their lives. We report the case of a 40-year-old morbidly obese woman with no significant past medical history, found to have intestinal malrotation on initial laparoscopic exploration for gastric bypass.

Gastric Bezoar Complicating Laparoscopic Adjustable Gastric Banding, and Review of Literature

Gastric bezoars may be formed in the normal stomach as a result of foreign body consecrations of various objects with inability to pass through the pylorus. Classically, most bezoars occur as a complication of gastric surgery which creates a low acid environment, decreased peristalsis, and abnormal pyloric function. Bariatric surgery has been associated with a low incidence of bezoar formation. However, to date there has been no documentation of bezoars occurring after laparoscopic adjustable gastric banding, which is one of the surgical options available for the treatment of morbid obesity. We report a case of a gastric bezoar that occurred 8 months after gastric banding.

Long-Term Outcome of Inferior Vena Cava Filter Placement in Patients Undergoing Gastric Bypass

BACKGROUNDnIt has been well established that inferior vena cava (IVC) filter placement at the time of open gastric bypass (OGB) surgery in patients with a body mass index of more than 55 kg/m(2) reduces both the pulmonary embolism rate and the perioperative mortality. However, little is known about the long-term effects of IVC filter placement in this particular group of patients.nnnMETHODSnOver an 8-year period, a total of 571 morbid obese patients underwent OGB procedures, and 58 (10%) of them required placement of an IVC filter before their procedure. All IVC filters were placed percutaneously through a femoral vein approach using a portable OEC fluoroscope. Types of IVC filters used in our study included the TrapEase (n = 35), Simon-Nitinol (n = 9), Greenfield (n = 2), and Bard Recovery (n = 12).nnnRESULTSnOf the 58 patients who required an IVC placement, 56 remained free of any thromboembolic phenomena over the 8-year period (range, 1-8 years). The remaining two patients developed deep venous thrombosis. One patient was successfully treated with intravenous heparin and a 6-month course of Coumadin. She had complete resolution of her deep venous thrombosis and was incidentally noted to have a prothrombin 20210 gene mutation. The other patient, who had multiple gastric bypass complications, could not be successfully treated with intravenous heparin and thus progressed on to complete IVC thrombosis. She developed phlegmasia cerulea dolens and required bilateral above-the-knee amputations. She subsequently died 3 months after her procedures.nnnCONCLUSIONnIt appears that IVC filter placement at the time of OGB surgery is a relatively benign intervention with a maximal benefit. A note of caution should be exerted for those obese patients who have a hypercoagulable disorder and for those who have complications related to the gastric bypass. An aggressive posture, which may consist of immediate anticoagulation after their procedures (only when it is deemed safe), should be advocated in this small sub-group of morbid obese patients.

Incidental gallbladder cancer and single-incision laparoscopic cholecystectomy

Dear Editor, I enjoyed reading the article about incidental gallbladder cancers and the role of re-resection [1]. Recently, I was called by a pathologist and informed that a gallbladder specimen with a large polyp was consistent with a gallbladder cancer—a T1 lesion. The patient had undergone surgery with another surgeon and physical examination revealed a single incision. When considering the possible technique used to retract and extract this gallbladder, I had reason for pause. Although this may not speak to all single-incision cholecystectomies, it is possible that the retraction process utilized for this procedure required the repeated passage of a needle through the body of the gallbladder, skin, and possibly the cancerous polyp. The gallbladder may have been opened or torn during the procedure. How was it extracted? With this in mind, even with a T1a gallbladder cancer, what do you do next? As we embark on the world of ‘‘even more’’ minimally invasive surgery, we should not discard all of the surgical principles that we once held in esteem. There was a time when while performing an ‘‘old fashioned’’ laparoscopic cholecystectomy, if we entered the gallbladder/spilled bile, this was considered personally disappointing. Now, we purposely do this and it seems to be accomplished without regard—until the specimen comes back with gallbladder cancer. The previous article cited that gallbladder cancer is found in only 0.2–2.9% of cholecystectomies and that incidental findings are found in 0.5–1% of laparoscopies [1, 2]. This is an exciting time in minimally invasive surgery because the keen mind can be free to imagine and implement more slick and consumer-friendly approaches to the world of surgery. As we move forward, this is something for all of us to think about: but first, do no harm.