Levan Tsamalaidze

Bariatric Surgery Is Gaining Ground as Treatment of Obesity After Heart Transplantation: Report of Two Cases

Experience with bariatric surgery in patients after orthotopic heart transplantation (OHT) is still limited. We performed a retrospective review of patients who underwent bariatric surgery after OHT from January 1, 2010 to December 31, 2016. Two post-OHT patients with BMI of 37.5 and 36.2 kg/m² underwent laparoscopic robotic-assisted Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, respectively. Quality of life substantially improved for both patients. Bariatric surgery is safe and feasible in OHT patients, despite numerous risk factors. Careful selection of patients is required with proper preoperative management and overall care. Due to the complexity of treatment and perioperative care in this specific population, these operations should be done in high-volume centers with multidisciplinary teams composed of bariatric, cardiac transplant surgeons and critical care physicians. Bariatric surgery can be highly effective for treatment of obesity after OHT.

Laparoscopic Sleeve Gastrectomy for Morbid Obesity in Patients After Orthotopic Liver Transplant: a Matched Case-Control Study

IntroductionObesity is frequently encountered in patients with orthotopic liver transplant (OLT). The role of bariatric surgery is still unclear for this specific population. The aim of this study was to review our experience with laparoscopic sleeve gastrectomy (LSG) after OLT.Material and MethodsWe performed a retrospective case-control study of patients undergoing LSG after OLT from 2010 to 2016. OLT-LSG patients were matched by age, sex, body mass index (BMI), and year to non-OLT patients undergoing LSG. Demographics, operative variables, postoperative events, and long-term weight loss with comorbidity resolution were collected and compared between cases and controls.ResultsOf 303 patients undergoing LSG, 12 (4%) had previous OLT. They were matched to 36 non-OLT patients. No difference was found between groups in the American Society of Anesthesiologists class, mean operative time, or postoperative morbidity. The non-OLT group, however, had a significantly shorter mean hospital stay than the OLT group (1.7 vs 3.1xa0days; Pxa0<xa0.001). There were no conversions to open procedures. For patients with long-term follow-up, change in BMI after LSG was similar between the groups, but the non-OLT patients had significantly more excess body weight loss at 2xa0years (53.7 vs 45.2%; Pxa0<xa0.001). Similar resolution of comorbid conditions was noted in both groups. LSG caused no changes in dosage of immunosuppressive medications, and no liver complications occurred.ConclusionLSG after OLT in appropriately selected patients appears to have similar outcomes to LSG in non-OLT patients.

Laparoscopic Duodenojejunostomy for the SMA Syndrome

OBJECTIVEnThe Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 1842. Clinical symptoms include postprandial pain, nausea, vomiting and weight loss. Duodenojejunostomy is the treatment of choice for patients with SMAS. We now present a case of a young female with SMAS who successfully underwent laparoscopic duodenojejunostomy.nnnINDICATIONSnThe first line treatment for SMAS is medical management, which includes infusion therapy, bowel rest, parenteral nutrition and a nasojejunal feeding tube inserted into the jejunum past the obstruction. If medical therapy fails, surgery is recommended.nnnPROCEDUREnA symptomatic patient with body mass index (BMI) of 19.4u2009kg/m2 underwent laparoscopic duodenojejunostomy. The patient tolerated the procedure well. The post-operative period was uneventful and the patient was discharged after three days. On six month follow up, the patient had gained weight and her symptoms were completely resolved.nnnCONCLUSIONnSMAS is still a poorly recognised pathology. A high index of suspicion should be given for patients with unclear causes of postprandial nausea, vomiting and abdominal pain, especially in young females. A laparoscopic approach seems to be safe and effective for patients with SMAS.

Solid Organ Transplantation and Bariatric Surgery

Obesity increases the risk for metabolic syndrome, diabetes, chronic kidney disease, cardiomyopathy, heart failure, fatty liver disease, and certain types of cancer while also causing increased health-care costs. Diabetes, often correlated with obesity, can result in chronic kidney disease and end-stage renal failure, while obesity itself can aggravate end-stage liver disease or cause nonalcoholic steatohepatitis (NASH). Bariatric surgery has demonstrated its safety and efficacy and may be beneficial for both pre- and posttransplant patients. Due to insufficient information in the literature about bariatric surgery in transplant patients, no definitive, ideal procedure exists. In this chapter, we evaluate features and outcomes of bariatric procedures (pre-, during, and posttransplant) in obese patients with solid organ (kidney, liver, and heart) transplantation. According to literature review and analysis, pure restrictive laparoscopic sleeve gastrectomy has demonstrated its superiority over the restrictive and malabsorptive Roux-en-Y gastric bypass operation in terms of safety, technical ease, and efficacy in transplant patients.

Pancreaticoduodenectomy: minimizing the learning curve

BackgroundnPancreaticoduodenectomy outcomes improve as surgeon experience increases. We analyzed the outcomes of pancreaticoduodenectomy for any improvements over time to assess the learning curve.nnnMethodsnA retrospective study of patients undergoing consecutive pancreaticoduodenectomy by a single surgeon at the beginning of practice was performed. Operative factors and 90-day outcomes were examined and trends over the course of the 4-year time period were analyzed.nnnResultsnBetween July 2011 and June 2015, 124 patients underwent pancreaticoduodenectomy (including total pancreatectomy, n=17) by open (n=93) or a laparoscopic (n=31) approach. The median operative time was 305 minutes which significantly improved over time. The median blood loss and length of stay were 250 mL and 6 days respectively which did not change over time. The pancreatic fistula rate, total morbidity, major morbidity, and mortality, and readmission rate was 7.5%, 41.1%, 14.5%, 1.6%, and 15.3% respectively and did not change over time. Pancreaticoduodenectomy was performed most commonly for pancreatic adenocarcinoma (51.6%) with a negative margin rate of 91.1% which significantly improved over time.nnnConclusionsnThe performance of pancreaticoduodenectomy improves as surgical experience is gained. However, a learning curve that impacts patient outcomes can be considerably diminished by appropriate training, high-volume practice/institution, proficient mentorship and experienced multidisciplinary team.

Postsplenectomy Thrombosis of Splenic, Mesenteric, and Portal vein (PST-SMPv): A single institutional series, comprehensive systematic review of a literature and suggested classification

OBJECTIVESnNo standard classification exists for post-splenectomy thrombosis of splenic, mesenteric, and portal vein (PST-SMPv). The goal of this study was to review our institutions experience with PST-SMPv and to perform a systematic literature review.nnnMETHODSnA retrospective review of all patients undergoing splenectomy from 1995-2016u202fat our institution was performed. Additionally, six databases and four grey literature websites were systematically searched. Splenectomy for pediatric patients or for trauma or portal hypertension related reasons were excluded.nnnRESULTSnBetween 1995 and 2016, 229 patients (113; 49.3% males) underwent splenectomy for spleen related diseases at our institution. From 1895 to 2016, 1645 unique literature citations were identified. Twenty citations met our inclusion criteria. Data on 1745 splenectomized patients was compiled; PST-SMPv occurred in 141 (8.1%).nnnCONCLUSIONSnIn our series, PST-SMPv developed in 6.6% of patients and the incidence of PST-SMPv after splenectomy in the literature ranges from 0.8 - 53.0%. A call for standardized reporting through a proposed classification is made.