Mayank Roy

Outcomes of bariatric surgery in patients >70 years old

BACKGROUND The aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States. METHODS A retrospective review was performed of prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities. RESULTS Of 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m(2), respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m(2), respectively. The median length of follow-up was 12 months (range 1-66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively. CONCLUSION Bariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.

Treatment option in patient presenting with small bowel obstruction from phytobezoar at the jejunojejunal anastomosis after Roux-en-Y gastric bypass.

Bezoar is a rare cause of small bowel obstruction after Roux-en-Y gastric bypass (RYGB). We report the case of a 34-year-old man who developed small bowel obstruction secondary to a phytobezoar at the jejunojejunal anastomosis, 5½ years after the patient underwent RYGB for morbid obesity. The phytobezoar developed in the background of recurring abdominal pain. Imaging studies suggested complete obstruction of the alimentary limb. Laparoscopic exploration demonstrated complete obstruction of the alimentary and biliopancreatic limb. Patient had successful treatment with laparoscopic enterototomy. Six months after the laparoscopic removal of phytobezoar, patient remained asymptomatic. Phytobezoar formation must be considered in the differential diagnosis when postgastric bypass patients present late with obstructive symptoms. We believe that this is the first report of a phytobezoar obstructing at the jejunojejunal anastomosis after RYGB.

Experience of laparoscopic paraesophageal hernia repair at a single institution

BACKGROUND Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy. METHODS Between January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients. RESULTS The average length of the surgery was 125 minutes (range, 51-304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1-14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%. CONCLUSIONS Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy combined with two-stage hepatectomy for multiple and bilobar desmoplastic small round cell tumor liver metastases

Desmoplastic small round cell tumor (DSRCT) is a rare mesenchymal tumor usually affecting young patients. Local dissemination is common, and liver is the most common site for extraperitoneal metastases. Multimodal management has been shown to be the most effective treatment. Some authors consider liver metastases especially bi-lobar disease as a contraindication for surgical resection. We present a case of a DSRCT with bi-lobar metastases in an adult patient who underwent multi-modal management along with hepatectomy. A 51-year-old man was found to have a large intraperitoneal mass with bi-lobar liver metastases during work up for new onset reflux and abdominal pain. Biopsy confirmed it as DSRCT. The patient was treated with multi-modal therapy including cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), two-stage hepatectomy (TSHP) combined with (90Y) Yittrium-90 radioembolization of the right hepatic lobe and systemic chemotherapy. The patient had a right-sided pleural empyema one month after the surgery for which he required right-sided video-assisted thoracoscopy and decortication. He remains disease free at 2 years follow-up. DSRCT with bi-lobar liver metastases are best managed with multimodal therapy. TSHP seems to be a feasible and safe option in selected cases, with a potentially good outcome.