Mariano Palermo

A Review of Studies Comparing Three Laparoscopic Procedures in Bariatric Surgery: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and Adjustable Gastric Banding

Obesity is a major worldwide problem in public health, reaching epidemic proportions in many countries, especially in urbanized regions. Bariatric procedures have been shown to be more effective in the management of morbid obesity, compared to medical treatments in terms of weight loss and its sustainability. The two most commonly performed procedures are laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric banding (LAGB), and the novel laparoscopic sleeve gastrectomy (LSG). The MEDLINE database (cutoff date September 2010), LILACS, and the Cochrane Library were searched using the key words “gastric bypass,” “sleeve gastrectomy,” and “gastric banding.” Only studies that compared at least two of the laparoscopic procedures were included. Reviews and meta-analysis, editorial letters or comments, case reports, animal or in vitro studies, comparisons with medical treatment, comparisons with open (non-laparoscopic) procedures were excluded. Most studies indicated that LRYGB and LSG could be more effective achieving weight loss than LAGB. However, LAGB seems to be a safer procedure with frequent, but less severe, long-term complications. Although not uniformly reported, a resolution of obesity-related comorbidities was achieved with most bariatric procedures. The three procedures have acceptable efficacy and safety. We believe that patients should be informed in detail on the advantages and disadvantages of each available procedure, possibly in several interviews and always accompanied by a specialized interdisciplinary team, warranting long-term follow-up.

Laparoscopic Whipple procedure: review of the literature

INTRODUCTION Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use. In the past, minimally invasive techniques were only used for diagnostic laparoscopy, staging of pancreatic cancer, and palliative procedures for unresectable pancreatic cancer. With new advances in technology and instrumentation, some sophisticated procedures are currently available, such as the Whipple procedure, one of the most sophisticated applications of minimally invasive surgery. MATERIALS AND METHODS A review of the literature shows that 146 laparoscopic Whipple procedures have been published worldwide since 1994. The authors analyzed blood loss, mean operating time, hospital stay, conversion rate, mean age, mortality rate, lymph nodes in the pathologic findings, follow up, and complications. RESULTS Mean age was 59.1 years; mean operating time was 439 min. The average blood loss for the reviewed literature was 143 mL; median hospital stay was 18 days; conversion rate was 46%; number of lymph nodes in the pathologic findings was 19; and mortalities related to the procedure was low, 2 patients (1.3%) and the complication rate was 16% (23/46 patients). Complications included 2 hemorrhages, 4 bowel obstructions, 1 stress ulcer, 1 delay of gastric emptying, 4 pneumonias, and 11 leaks. CONCLUSION This review demonstrates that the laparoscopic Whipple procedure is not only feasible but also safe, with low mortality and acceptable rates of complications.

Gastrocolic fistula after re-sleeve gastrectomy: outcomes after esophageal stent implantation

Gastrocolic fistula after re-sleeve gastrectomy: outcomes after esophageal stent implantation Nelson Trelles, M.D., Michel Gagner, M.D., F.R.C.S.C., F.A.C.S.*, Mariano Palermo, M.D.*, Alfons Pomp, M.D., F.R.C.S.C., F.A.C.S., Gregory Dakin, M.D., F.A.C.S., Manish Parikh, M.D. Department of Surgery, Mount Sinai Medical Center, Miami Beach, Florida Division of Laparoscopic and Bariatric Surgery, Department of Surgery, New York Presbyterian Hospital and Joan and Sanford I. Weill Medical College of Cornell University, New York, New York Received August 10, 2009; revised August 13, 2009; accepted August 13, 2009

BIODEGRADABLE BILIARY STENTS: A NEW APPROACH FOR THE MANAGEMENT OF HEPATICOJEJUNOSTOMY STRICTURES FOLLOWING BILE DUCT INJURY. PROSPECTIVE STUDY

ABSTRACT Background: Once a biliary injury has occurred, repair is done by a hepaticojejunostomy. The most common procedure is to perform a dilatation with balloon with a success of 70 %. Success rates range using biodegradable stents is from 85% to 95%. Biodegradable biliary stents should change the treatment of this complication. Aim: To investigate the use of biodegradable stents in a group of patients with hepaticojejunonostomy strictures. Methods: In a prospective study 16 biodegradable stents were placed in 13 patients with hepaticojejunostomy strictures secondary to bile duct repair of a biliary surgical injury. Average age was 38.7 years (23-67), nine were female and four male. All cases had a percutaneous drainage before at the time of biodegradable stent placement. Results: In one case, temporary haemobilia was present requiring blood transfusion. In another, pain after stent placement required intravenous medication. In the other 11 patients, hospital discharge was the next morning following stent placement. During the patient´s follow-up, none presented symptoms during the first nine months. One patient presented significant alkaline phosphatase elevation and stricture recurrence was confirmed. One case had recurrence of cholangitis 11 months after the stent placement. 84.6% continued asymptomatic with a mean follow-up of 20 months. Conclusion: The placement of biodegradable stents is a safe and feasible technique. Was not observed strictures caused by the stent or its degradation. It could substitute balloon dilation in strictures of hepaticojejunostomy.

HERNIOPLASTY WITH AND WITHOUT MESH: ANALYSIS OF THE IMMEDIATE COMPLICATIONS IN A RANDOMIZED CONTROLLED CLINICAL TRIAL

Background: Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects. Aim: Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty. Method: Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence. Results: The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh. Conclusions: The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.

Laparoscopic Revisional Hepaticojejunostomy for Biliary Stricture After Open Repair Following Common Bile Duct Injury: A Case Report

Introduction. Incidence of bile duct injury has been reported more frequently following laparoscopic cholecystectomy. Case Report. A 43-year-old female with a past medical history of laparoscopic cholecystectomy that was converted to open because of a common bile duct injury now presents with a stenosis at the hepaticojejunostomy that is causing recurrent cholangitis episodes. After the lysis of adhesions and dissection of the anastomotic area, a stricture was identified. The authors exposed and redid the hepaticojejunostomy with 4-0 Monocryl sutures without tension. The follow-up period was unremarkable. No leaks were documented, and the patient was discharged home on postoperative day 3. Conclusion. After percutaneous or endoscopic procedure failure for the treatment of hepaticojejunostomy strictures, the laparoscopic redo anastomosis is safe and feasible when performed by surgeons who are strongly trained in advanced laparoscopic surgery.

Interventional Radiology, Is There a Role for the Surgeon?

Obesity is a growing problem all over the world, especially in the United States, Europe, and Australia. Currently, bariatric surgery offers the only effective long-term weight loss therapy for morbidly obese patients. Increased media attention to these procedures as well as the newer option of laparoscopic treatment has led patients and surgeons to embrace this surgical option in an elevated number, particularly the option of Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG). Obesity surgery also has significant rates of complications, which can be as high as 32.8%, such as anastomotic or staple line leaks, abdominal abscess, gastrointestinal bleeding, intestinal obstruction, anastomotic strictures, choledocholithiasis in patients with modified anatomy due to RYGB, and acute gastric dilatation, among others.

Biliary Disease and Bariatric Surgery

It is known that the rapid weight loss is a predisposing factor to develop biliary lithiasis. Compared with the general population, the obese have high levels of serum cholesterol, determining a higher incidence of lithiasis, which is further increased in the patient population undergoing a bariatric procedure. Furthermore, after bariatric surgery, a decrease in the gallbladder motility due to nerve damage, a deficit in phospholipids and contraction-stimulating proteins, and an increase of mucin secretion toward the gallbladder occur, leading to an acceleration of the nucleation process.

NECROTIZING PANCREATITIS: DESCRIPTION OF VIDEOSCOPIC ASSISTED RETROPERITONEAL DEBRIDEMENT (VARD) TECHNIQUE WITH COVERED METALLIC STENT

ABSTRACT Background : Acute pancreatitis is the third most common gastrointestinal disorder requiring hospitalization in the United States, with annual costs exceeding

Single Port Laparoscopic Gastrostomy

2 billions. Severe necrotizing pancreatitis is a life-threatening complication developed in approximately 20% of patients. Its mortality rate range from 15% in patients with sterile necrosis to up 30% in case of infected one associated with multi-organ failure. Less invasive treatment techniques are increasingly being used. These techniques can be performed in a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement (Vard technique) with covered metallic stent in necrotizing pancreatitis. Method: A guide wire was inserted through the previous catheter that was removed in the next step. Afterwards, the tract was dilated over the guide wire. Then, a partially covered metallic stent was deployed. A 30 degrees laparoscopic camera was inserted and the necrosis removed with forceps through the expanded stent under direct vision. Finally, the stent was removed and a new catheter left in place. Result : This technique was used in a 31-year-old man with acute pain in the upper abdomen and diagnosed as acute biliary pancreatitis with infected necrosis. He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial recovery, a left lateral VARD was performed (incomplete by fixed and adherent tissue) at 8th week. As the patient´s inflammatory response was reactivated, a second VARD attempt was performed in three weeks later. Afterwards, patient showed complete clinical and imaging resolution. Conclusions : Videoassisted retroperitoneal necrosectomy using partially covered metallic stent is a feasible technique for necrotizing pancreatitis.