Pavlos K. Papasavas

Laparoscopic management of complications following laparoscopic Roux-en-Y gastric bypass for morbid obesity

Background: We reviewed our experience with complications following laparoscopic Roux-en-Y gastric bypass (LRYGB) that were managed laparoscopically. Methods: A total of 246 consecutive morbidly obese patients (mean body mass index, 50.9 kg/m2) underwent LRYGB by three surgeons at two institutions. All patients met National Institutes of Health criteria for surgical treatment of morbid obesity. Patients were followed prospectively. Results: A total of 62 patients (25.2%) developed 64 complications, 34 of which (13.8%) required a surgical intervention. Twenty-seven of the 34 procedures were performed laparoscopically. Gastrojejunostomy stricture was the most common complication (8.9%), followed by intestinal obstruction (7.3%) and gastrointestinal bleeding (4%). The intestinal obstruction was secondary to adhesions (n = 6), internal hernia at the level of the transverse mesocolon (n = 3), jejunojejunostomy stricture (n = 3), and cicatrix around the Roux limb at the level of the transverse mesocolon (n = 3). Other complications included gastrojejunostomy leak (1.6%), symptomatic gallstone disease (2.8%), and gastric remnant perforation (0.8%). One patient underwent a negative laparoscopy to rule out anastomotic leak. There were 3 deaths in this series of patients, 2 attributable to anastomotic leak. Conclusions: A variety of complications can present after LRYGB. Laparoscopy is an excellent technique to treat these complications.

An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room

Objective:To assess the use of a synchronized video-based motion tracking device for objective, instant, and automated assessment of laparoscopic skill in the operating room. Summary Background Data:The assessment of technical skills is fundamental to recognition of proficient surgical practice. It is necessary to demonstrate the validity, reliability, and feasibility of any tool to be applied for objective measurement of performance. Methods:Nineteen subjects, divided into 13 experienced (performed >100 laparoscopic cholecystectomies) and 6 inexperienced (performed <10 LCs) surgeons completed LCs on 53 patients who all had a diagnosis of biliary colic. Each procedure was recorded with the ROVIMAS video-based motion tracking device to provide an objective measure of the surgeons dexterity. Each video was also rated by 2 experienced observers on a previously validated operative assessment scale. Results:There were significant differences for motion tracking parameters between the 2 groups of surgeons for the Calot triangle dissection part of procedure for time taken (P = 0.002), total path length (P = 0.026), and number of movements (P = 0.005). Both motion tracking and video-based assessment displayed intertest reliability, and there were good correlations between the 2 modes of assessment (r = 0.4 to 0.7, P < 0.01). Conclusions:An instant, objective, valid, and reliable mode of assessment of laparoscopic performance in the operating room has been defined. This may serve to reduce the time taken for technical skills assessment, and subsequently lead to accurate and efficient audit and credentialing of surgeons for independent practice.

Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity

BackgroundGastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass (LRYGBP) present with dysphagia, nausea, and vomiting. Diagnosis is made by endoscopy and/or radiographic studies. Therapeutic options include endoscopic dilation and surgical revision.MethodsOf 369 LRYGBP performed, 19 patients developed anastomotic stricture (5.1%). One additional patient was referred from another facility. Pneumatic balloons were used for initial dilation in all patients. Savary-Gilliard bougies were used for some of the subsequent dilations.ResultsFlexible endoscopy was diagnostic in all 20 patients allowing dilation in 18 (90%). Two patients did not undergo endoscopic dilation because of anastomotic obstruction and ulcer. The median time to stricture development was 32 days (range: 17–85). Most patients (78%) required more than two dilations. The complication rate was 1.6% (one case of microperforation). At a mean follow-up of 21 months, all patients were symptom-free.ConclusionsGastrojejunostomy stricture following LRYGBP is associated with substantial morbidity and patient dissatisfaction. Based on our experience, we propose a clinical grading system and present our strategy for managing gastrojejunal strictures.

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography for benign common bile duct stricture after Roux-en-Y gastric bypass

Access to the gastric remnant and duodenum is lost after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Traditionally, a percmaneous transhepatic access to the common bile duct has been used to manage choledocholithiasis and duct strictures. We present a novel method of laparoscopic transgastric endoscopic retrograde cholangiopancreatography for managing a benign biliary stricture after a Roux-en-Y gastric bypass

Cholecystectomy vs cholecystostomy in high risk surgical patients

Purpose: Emergency cholecystectomy under general anesthesia has been associated with high morbidity and mortality in critically ill patients. Percutaneus cholecystostomy was advocated as preferred treatment in high surgical risk patients. Hypothesis: Cholecystostomy is preferable treatment of acute cholecystitis in critically ill patients. Methods: Between 1997 and 2003 charts of 153 patients who underwent cholecystectomy or cholecystostomy secondary to acute cholecystitis were reviewed. 37 cholecystectomies and 28 cholecystostomies with ASA class III and IV were selected for study. Demographic data, comorbidities, procedure details, diagnostic data and outcomes were collected. APACHE II score at the day of diagnosis and 3 postoperative date, mortality 1, 3 postpoperative day and same hospital admission mortality was calculated. Comparison was made between cholecystostomy and cholecystectomy groups. Results: High surgical risk patients (ASA III and IV) with ac cholecystitis were divided in 2 groups: cholecystectomy and cholecystostomy.