Ram Elazary

Dilated Upper Sleeve Can be Associated with Severe Postoperative Gastroesophageal Dysmotility and Reflux

BackgroundLaparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure, and it can be done as an isolated LSG or in conjunction with biliopancreatic diversion bypass/duodenal switch (laparoscopic duodenal switch; LDS). Gastroesophageal reflux after LSG has been described, but the mechanism is unknown and the treatment in the severest cases has not been discussed. We describe a cohort of patients who have underwent an LSG or LDS, and have suffered from a severe postoperative gastroesophageal motility disorder and/or reflux, report on their treatment, and discuss possible underlying mechanisms.MethodsSeven hundred and six patients underwent an LSG by two of the authors (AK, AB). Sixty nine patients underwent laparoscopic sleeve gastrectomy in Hadassah Medical Center, Jerusalem, Israel (January, 2006 and December 2008; 55 isolated LSG, 14 with LDS), and 637 (212 isolated LSG, 425 LDS) in Clinica San Jorge and Alcoy Hospital in Alcoy, Spain, (January 2002 and November 2008).ResultsOf them, eight patients who has suffered from a gastroesophageal dysmotility and reflux disease postoperatively and needed a specific treatment besides regular proton pump inhibitors (PPIs) were identified (1.1%).ConclusionA combination of dilated upper part of the sleeve with a relative narrowing of the midstomach, without complete obstruction, was common to all eight patients who suffered from a severe gastroesophageal dysmotility and reflux. The sleeve volume, the bougie size, and the starting point of the antral resection do not seem to have an effect in this complication. Operative treatment was needed in only one case out of eight; in the rest of the patients, medical modalities were successful. More knowledge is required to understand the underlying mechanisms.

Suicide bombing attacks: Can external signs predict internal injuries?

Objective:To report the distribution and types of injuries in victims of suicide bombing attacks and to identify external signs that would guide triage and initial management. Summary Background Data:There is a need for information on the degree to which external injuries indicate internal injuries requiring emergency triage. Methods:The medical charts and the trauma registry database of all patients who were admitted to the Hadassah Hospital in Jerusalem from August 2001 to August 2004 following a suicide bombing attack were reviewed and analyzed for injury characteristics, number of body areas injured, presence of blast lung injury (BLI), and need for therapeutic laparotomy. Logistic analysis was performed to identify predictors of BLI and intra-abdominal injury. Results:The study population consisted of 154 patients who were injured as a result of 17 attacks. Twenty-eight patients suffered from BLI (18.2%) and 13 patients (8.4%) underwent therapeutic laparotomy. Patients with penetrating head injury and those with ≥4 body areas injured were significantly more likely to suffer from BLI (odds ratio, 3.47 and 4.12, respectively, P < 0.05). Patients with penetrating torso injury and those with ≥4 body areas injured were significantly more likely to suffer from intra-abdominal injury (odds ratio, 22.27 and 4.89, respectively, P < 0.05). Conclusion:Easily recognizable external signs of trauma can be used to predict the occurrence of BLI and intra-abdominal injury. The importance of these signs needs to be incorporated into triage protocols and used to direct victims to the appropriate level of care both from the scene and in the hospital.

Single-incision laparoscopic cholecystectomy: lessons learned for success.

Since its introduction approximately 20 years ago, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis [1–3]. Conventional laparoscopic cholecystectomy generally is performed through four small incisions in the abdominal wall [4]. In recent years, a less invasive method has been sought in an effort to reduce postoperative pain and morbidities such as wound infection and trocar-site hernias while further enhancing the cosmetic results. Initial attempts to perform the procedure through three and then two ports or with reduced-diameter trocars (needlescopic surgery) [5–9] have since been superseded by even less invasive and more innovative techniques, namely, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) [10–13]. Single-incision laparoscopic surgery is an attractive technique for cholecystectomy due to its superior cosmetic results and potential to reduce the rate of wound complications such as infection, hematoma, and hernia. This technique, however, is not straightforward. The technical complexity of SILS naturally results in a steep learning curve and increased operating room time and requires specialized equipment. The primary technical obstacles of SILS currently include Collision of instruments both within and outside the abdomen as a result of their common entry point (“sword fighting”) Inadequate triangulation Compromised field of view due to obstruction by instruments entering the common port Inadequate exposure and retraction. Several techniques have since evolved to overcome these potential pitfalls [14–16]. By incorporating a number of these techniques, we have created a simplified technique that has proved successful with both animal and human subjects. We describe both our experience and what we have learned, which have allowed simplification of a technical complex procedure.

Providing more through less: current methods of retraction in SIMIS and NOTES cholecystectomy

BackgroundAs the field of minimally invasive surgery continues to develop, surgeons are confronted with the challenge of performing conventional laparoscopic surgeries through fewer incisions while maintaining the same degree of safety and surgical efficiency. Most of these methods involve elimination of the ports previously designated for retraction. As a result, minimally invasive surgeons have been forced to develop minimally invasive and ingenious methods for providing adequate retraction for these procedures. Herein we present our experience using endoloops and internal retractors to provide retraction during Single Incision Minimally Invasive Surgery (SIMIS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy. We also present a review of the alternative retraction methods currently being employed for these surgeries.MethodsSIMIS was performed on 20 patients and NOTES was performed on 5 patients at our institution. Endoloops or internal retractors were used to provide retraction for all SIMIS procedures. Internal retractors provided retraction for all NOTES procedures.ResultsSuccessful cholecystectomy was accomplished in all cases. One SIMIS surgery required conversion to standard laparoscopy due to complex anatomy. There were no intraoperative complications. Although adequate retraction was accomplished in all cases, the internal retractors were found to provide superior and more versatile retraction compared to that of endoloops.ConclusionAdequate retraction greatly simplifies SIMIS and NOTES surgery. Endograb internal retractors were easy to use and were found to provide optimal retraction and exposure during these procedures without complications.

Nutritional deficiencies after sleeve gastrectomy: can they be predicted preoperatively?

BACKGROUND Nutritional deficiencies are common among morbidly obese patients. Data are scarce for patients who have undergone laparoscopic sleeve gastrectomy (LSG). OBJECTIVES The aim of the study is to clarify the prevalence of deficiencies and to identify risk factors for postoperative deficiencies. SETTINGS Hebrew University, Israel. METHODS Preoperative and 1-year postoperative data were collected. We included anthropometric parameters, obesity-related co-morbidities, and laboratory findings. RESULTS There were 192 candidates. Seventy-seven of them completed follow-ups at 12 months. Before surgery, 15% had anemia. Deficiencies of iron, folate, and B12 were 47%, 32%, and 13%, respectively. Women were more deficient in iron (56% women, 26% men, P<.001). Before surgery, low levels of vitamin D and elevated parathyroid hormone (PTH) were 99% and 41%, respectively. One year postsurgery, the deficiencies of hemoglobin and vitamin B12 worsened (20% and 17%, P<.001, P = .048, respectively). One year postsurgery, deficiencies of iron, folate, vitamin D, and PTH improved (28%, 21%, 94%, and 10%, respectively). Deficiencies of hemoglobin, folate, and B12 before surgery were predictors for deficiencies 1 year after surgery (P = .006 OR = .090; P = .012 OR = .069; P = .062 OR = .165, respectively). CONCLUSIONS LSG had a modest effect on nutritional deficiencies in our patients at 1-year postsurgery. Focusing on the preoperative nutritional status and tailoring a specific supplemental program for each individual should prevent postoperative deficiencies.

Intra-arterial thrombolysis and stent placement for traumatic carotid dissection with subsequent stroke: a combined, simultaneous endovascular approach.

Traumatic carotid dissection is a well-known cause of ischemic stroke and although the treatment of the dissection itself has received some attention in recent years, the treatment of the concomitant stroke has been less investigated. We present a 43-year-old patient with blunt traumatic internal carotid artery dissection associated with subocclusive stenosis and major cerebral thromboembolic complication. Combined, simultaneous intra-arterial fibrinolysis and carotid stenting through a bilateral approach was successfully performed allowing the complete clinical recovery of the patient. Contralateral carotid artery approach allowed the beginning of intra-arterial thrombolysis without delay, while stent-assisted angioplasty of the injured carotid was simultaneously performed. This approach was proved to be safe and effective and may deserve further evaluation.

Nutritional deficiencies four years after laparoscopic sleeve gastrectomy—are supplements required for a lifetime?

BACKGROUND Data regarding long-term nutritional deficiencies following laparoscopic sleeve gastrectomy (LSG) are scarce. OBJECTIVES To assess the prevalence of nutritional deficiencies and supplement consumption 4 years post-LSG. SETTING Hebrew University, Israel. METHODS Data were collected prospectively from preoperative and 1 and 4 years postoperative including anthropometric parameters, biochemical tests, and supplement intake. RESULTS Data were available for 192, 77, and 27 patients at presurgery and 1 and 4 years post-LSG, respectively. Prevalence of nutritional deficiencies at baseline and 1 and 4 years postsurgery, respectively, were specifically for iron (44%, 41.2%, 28.6%), anemia (11.5%, 20%, 18.5%), folate (46%, 14.3%, 12.5%), vitamin B12 (7.7%, 13.6%, 15.4%), vitamin D (96.2%, 89%, 86%), and elevated parathyroid hormone (PTH) (52%, 15.4%, 60%). Vitamin D levels remained low throughout the whole period. PTH levels were 37.5 pg/mL at 1 year postsurgery and increased to 77.3 pg/mL at 4 years postsurgery (P = .009). Females had higher prevalence of elevated PTH and a tendency for higher rates of anemia, compared with males 4 years postsurgery (80% versus 20%, P = .025; and 28% versus 0%, P = .08, respectively). Of the patients, 92.6% reported taking a multivitamin and 74.1% vitamin D supplements during the first postoperative year, while after 4 years only 37% and 11.1% were still taking these supplements, respectively. CONCLUSION A high rate of nutritional deficiencies is common at 4 years post-LSG along with low adherence to the nutritional supplementation regimen. Long-term nutritional follow-up and supplementation maintenance are crucial for LSG patients. Future studies are needed to clarify the clinical impact of such deficiencies.

Abdominal thrombotic complications following bariatric surgery.

BACKGROUND Thrombotic events involving the portal-splenic-mesenteric venous system (PSMVT) are rare but potentially lethal after bariatric surgery. OBJECTIVES To investigate the incidence, clinical presentation, management, and outcome of thrombotic events after bariatric surgery. SETTING Two university hospitals. METHODS A retrospective review of individuals who underwent bariatric surgery between January 2006 and December 2015. RESULTS Overall, 4386 patients underwent bariatric surgery (laparoscopic sleeve gastrectomy [LSG; n = 2886], laparoscopic Roux-en-Y gastric bypass [n = 762], laparoscopic adjustable gastric banding [n = 668], and biliopancreatic diversion [n = 70]). Mechanical (thigh-length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40 mg enoxaparin daily, starting 12 hours after surgery until discharge) was provided for all patients. A minority of patients (n = 543, 12.4%) also received an extended course of enoxaparin for 1-4 weeks after discharge. We observed 16 cases of PSMVT, all after LSG, with an incidence of .55% (16/2886). Twelve additional patients experienced deep vein thrombosis and 6 had pulmonary embolism. Follow-up imaging indicated complete resolution in all cases, with no sequelae, recurrent thrombosis, or mortality. The overall thrombosis rate was significantly lower in patients who received an extended course of anticoagulation after LSG (P = .01) and after any type of bariatric surgery (P = .02). CONCLUSIONS PSMVT was found to occur uncommonly after LSG. Prompt diagnosis and anticoagulation therapy led to favorable outcomes in most cases. Significantly lower rates of thrombosis were found in patients who received an extended course of anticoagulation. We support its use for at least 1 week after discharge.

Malignant Appendiceal GIST: Case Report and Review of the Literature

IntroductionGastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only a handful has been described in the literature, all of which have been of the benign type.Case ReportWe present the first reported case of a malignant appendiceal GIST. The tumor was discovered when the patient presented with a peri-appendiceal abscess which appeared suspicious on CT. The abscess was drained and managed medically. The patient responded to antibiotic treatment but subsequent CT and biopsy confirmed the diagnosis of appendiceal GIST, and the patient was started on treatment with imatinab mesylate.DiscussionOne week after initiation of therapy, the patient returned with frank peritonitis necessitating surgery. Abdominal exploration revealed an appendiceal GIST locally invading and perforating adjacent bowel. We describe the complex presentation and course of the case as well as a literature review of the appendiceal GISTs and the current approach to treatment.

Sleeve gastrectomy and mesenteric venous thrombosis: report of 3 patients and review of the literature

haim Mesenteric venous thrombosis (MVT) is a rare but potentially lethal pathology. Although first described by Balfour and Stewart in 1869 [1], it was first presented as a distinct cause of mesenteric ischemia by Warren and Eberhand only in 1935 [2]. MVT accounts for 5%–15% of all mesenteric ischemic events [2,3]. In the past, MVT has been described after procedures involving manipulation of the portal venous system, such as splenectomy or liver transplantation [4,5]. However, since the beginning of the minimal invasive era, MVT has occurred in several cases after various laparoscopic procedures [6]. During the last decade, a few cases of MVT have been published to occur after laparoscopic bariatric operations, including laparoscopic sleeve gastrectomy (LSG) [7]. Nevertheless, MVT has been shown to be a major morbidity during the perioperative period of LSG with an incidence of 1% [8]. The aim of this article is to present 3 cases of MVT that have occurred after 900 LSG procedures in our center, discuss the pathophysiology and management of this complication and suggest preventive strategy.