Paul R. Kemmeter

Percutaneous Thrombin Injection of Splanchnic Artery Aneurysms: Two Case Reports

JVIR 2000; 11:469–472 THE diagnosis and management of splanchnic artery aneurysms is difficult. The first reported splanchnic artery aneurysm was discovered while Beaussier was injecting a cadaver for anatomic demonstration in 1770 (1). Since then, more than 3,000 cases of splanchnic artery aneurysms have been documented in the literature. However, the incidence of such aneurysms is not known. Although rare, these lesions are clinically important. Nearly 22% of all splanchnic artery aneurysms present as clinical emergencies. Of these, 8.5% result in death (2). The majority of aneurysms (63%) are symptomatic at the time of presentation and 23.9% present with rupture (3). The treatment of choice of splanchnic artery aneurysms classically has been operative ligation or resection. With the advancement of interventional radiology, percutaneous transcatheter embolization has been effective (4). Unfortunately, not all aneurysms can be successfully cannulated with these catheters (4). In 1986, Cope and Zeit described the successful treatment of pseudoaneurysms of the peripheral arteries by direct percutaneous injection of thrombin (5). In 1989, Rothbarth et al reported a case in which they successfully treated a large intraparenchymal hepatic artery aneurysm by percutaneously injecting thrombin after embolization with coils had failed (6). The purpose of this article is to describe the use of percutaneous thrombin injection for the treatment of ruptured aneurysms involving branches of the superior mesenteric artery. Two patients presented to our institution with symptoms related to rupture of splanchnic artery aneurysms.

A new method for estimation of involved BSAs for obese and normal-weight patients with burn injury.

An accurate measurement of BSA involved in patients injured by burns is critical in determining initial fluid requirements, nutritional needs, and criteria for tertiary center admissions. The rule of nines and the Lund-Browder chart are commonly used to calculate the BSA involved. However, their accuracy in all patient populations, namely obese patients, remains to be proven. Detailed BSA measurements were obtained from 163 adult patients according to linear formulas defined previously for individual body segments. Patients were then grouped based on body mass index (BMI). The contribution of individual body segments to the TBSA was determined based on BMI, and the validity of existing measurement tools was examined. Significant errors were found when comparing all groups with the rule of nines, which overestimated the contribution of the head and arms to the TBSA while underestimating the trunk and legs for all BMI groups. A new rule is proposed to minimize error, assigning 5% of the TBSA to the head and 15% of the TBSA to the arms across all BMI groups, while alternating the contribution of the trunk/legs as follows: normal-weight 35/45%, obese 40/40%, and morbidly obese 45/35%. Current modalities used to determine BSA burned are subject to significant errors, which are magnified as BMI increases. This new method provides increased accuracy in estimating the BSA involved in patients with burn injury regardless of BMI.

Esophagectomy outcomes at a mid-volume cancer center utilizing prospective multidisciplinary care and a 2-surgeon team approach

BACKGROUND Esophagectomy is associated with high morbidity and mortality, leading to calls for restricted performance at high-volume centers. METHODS Patients with esophageal cancer were evaluated prospectively in a multidisciplinary tumor board from January 2012 - December 2012. A 2-surgeon team was utilized and detailed outcomes were assessed prospectively. RESULTS Thirty-one patients underwent esophagectomy, 20 patients underwent laparoscopic transhiatal (65%) approach, and 11 patients underwent laparoscopically assisted Ivor-Lewis (35%) approach. Eighty-one percent of the patients were male, with a median age of 64 years (range: 35 to 83 years) and 73% of the patients had adenocarcinoma. Neoadjuvant chemoradiation was performed in 79% of the patients. R0 resection was achieved in 29 (94%) patients, median nodes identified were 15. Major complications (grade III to V) occurred in 13 (42%) patients and did not correlate with surgical techniques, anastomotic leak occurred in 5 (16%) patients, and significant pulmonary complications occurred in 11 (35%) patients. The length of stay at the hospital was 10 days, readmission rate 23%, and 30-day mortality rate 6%. CONCLUSIONS High-quality esophagectomy can be performed safely at a mid-volume cancer center. Our outcomes question the reliance on volume alone as an indicator of cancer surgical quality.

Effect of Center of Excellence requirement by Centers for Medicare and Medicaid Services on practice trends

BACKGROUND To report the effect of the American Society of Bariatric Surgery or American College of Surgeons-designated Centers of Excellence designation in Michigan on our practice trends and patient populations. As of February 2006, weight loss surgery for Medicare beneficiaries are reimbursed when procedures are performed at American Society of Bariatric Surgery or American College of Surgeons-designated Centers of Excellence. METHODS Patients who underwent laparoscopic Roux-en-Y gastric bypass surgery by an individual surgeon from June 1 to October 31 in 2004, 2005, and 2006 were stratified according to use of private third-party insurance versus Medicare (MC) insurance. The demographic data, body mass index, numbers of medications and co-morbidities, operative time, lengths of stay, morbidity, and mortality were analyzed. Significance was assessed at P <.05. RESULTS From June 1 to October 31 in 2004, 2005, and 2006, 255 patients with MC or private third-party insurance underwent laparoscopic Roux-en-Y gastric bypass surgery, with the percentage of MC patients increasing from 15.3% and 10.2% in 2004 and 2005 to 30.9% in 2006. The MC patients were older (56.1 +/- 1.3 yr versus 44.1 +/- 0.7 yr; mean +/- standard error of mean), had more co-morbidities (5.1 +/- 0.2 versus 3.5 +/- 0.1), required more medications (10.3 +/- 0.6 versus 5.6 +/- 0.3), had undergone more previous operations (2.1 +/- 0.2 versus 1.3 +/- 0.1), and had longer operative times (148 +/- 11.1 versus 121 +/- 3.1 min) than the private third-party insurance patients; the differences were all significant. The differences in gender, body mass index, and length of stay were not significantly different. CONCLUSION The Centers for Medicare and Medicaid Services requirements for Centers of Excellence designation resulted in a significant increase in the Medicare case load within our institution. This population tended to be older and more complex, with longer operative times. The changes present new challenges in patient care, including the coordination of care for the multiple co-morbidities of older obese patients with a multispecialty care team.

Evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients

BACKGROUND Both hiatal hernias (HH) and morbid obesity significantly contribute to gastroesophageal reflux disease, which increases the risk for esophagitis and esophageal cancer. Therefore, concomitant HH repair is recommended during bariatric surgery procedures. Unfortunately, recurrence of HH after repair is not uncommon and the optimal surgical technique has yet to be established. OBJECTIVE To evaluate the feasibility of recreating the phrenoesophageal ligaments by adding phrenoesophagopexy to HH repair during sleeve gastrectomy. SETTING Independent, university-affiliated teaching hospital. METHODS Retrospective chart review of all patients with a body mass index ≥35 kg/m2 who underwent a combined sleeve gastrectomy and HH repair between January 2010 and December 2014 by a single surgeon at a single institution. Demographic data and 30-day postoperative complications rates were obtained. RESULTS There were 106 patients evaluated. Mean age was 50.8 ± 12.5 years, mean body mass index was 45.8 ± 7.1 kg/m2, and 87% were female. Mean operative time was 112 ± 24.5 minutes, and mean length of stay was 1.9 ± .7 days. The 30-day complication rate was .94% (1 gastric sleeve leak) and there were no deaths. Six patients (5.7%) required emergency department evaluation, and 5 (4.7%) required readmission for abdominal pain (2), dysphagia/dehydration (1), esophagitis (1), or gastric sleeve leak (1), which required reoperation. CONCLUSION The addition of an interrupted phrenoesophagopexy for HH repair during sleeve gastrectomy appears to be a feasible technique with low 30-day morbidity and mortality rates. Long-term follow-up is needed to evaluate the efficacy in reducing HH recurrence rates.

Laparoscopic Transhiatal Esophagectomy after Biliopancreatic Diversion with Duodenal Switch

Laparoscopic transhiatal esophagectomy after biliopancreatic diversion with duodenal switch Deepali H. Jain, M.D.*, Tedi S. Vlahu, M.D., Paul R. Kemmeter, M.D., Jill K. Onesti, M.D. Grand Rapids Medical Education Partners, Department of Surgery, Grand Rapids, Michigan Michigan State University, College of Human Medicine, Grand Rapids, Michigan Grand Health Partners, Grand Rapids, Michigan Mercy Health Saint Mary’s, Grand Rapids, Michigan Received July 20, 2017; accepted October 10, 2017

A matched cohort study of laparoscopic biliopancreatic diversion with duodenal switch and sleeve gastrectomy performed by one surgeon

SETTING Spectrum Blodgett and Mercy Health St. Marys hospitals in Grand Rapids, Michigan OBJECTIVE: To compare the 30-day outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) to laparoscopic sleeve gastrectomy (SG). BACKGROUND Laparoscopic BPD/DS has been shown to be superior to SG in terms of excess weight loss. Despite this superiority, BPD/DS accounts for a small percentage of all metabolic surgeries due partly to the perception that BPD/DS has a higher complication rate than SG. METHODS Retrospective review of all patients who underwent BPD/DS or SG from January 2008 to August 2014 by 1 surgeon was completed. These patients were used to construct cohorts matched via propensity score matching and compared by surgical type. Data collected included patient demographic characteristics; hospital length of stay (LOS); and 30-day rates of leak, bleed, reoperation, readmission, and mortality. RESULTS Of the 741 patients who underwent BPD/DS or SG, 2 cohorts of 167 patients each were matched for age, sex, and BMI. LOS was longer in the BPD/DS cohort (2.5±.9 days versus 2.1±.7 days, P<.001). There were no significant differences between the groups in relation to 30-day postoperative rates of leak (.3% versus .6%, P>.99), bleed (0% versus .3%, P>.99), reoperation (1.2% versus .6%, P>.99), or readmission (3% versus 1.2%, P = .45). There were no mortalities. CONCLUSION After matching for age, sex, and BMI, BPD/DS found no significant differences from SG with regard to 30-day postoperative rates of leak, bleed, reoperation, readmission, or mortality.