Ramsey M. Dallal

Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications.

ObjectiveTo review the epidemiology and characteristics of patients who died or underwent colectomy secondary to fulminant Clostridium difficile colitis. Summary Background DataIn patients with C. difficile colitis, a progressive, systemic inflammatory state may develop that is unresponsive to medical therapy; it may progress to colectomy or death. MethodsThe authors reviewed 2,334 hospitalized patients with C. difficile colitis from January 1989 to December 2000. Sixty-four patients died or underwent colectomy for pathologically proven C. difficile colitis. ResultsIn 2000, the incidence of C. difficile colitis in hospitalized patients increased from a baseline of 0.68% to 1.2%, and the incidence of patients with C. difficile colitis in whom life-threatening symptoms developed increased from 1.6% to 3.2%. Forty-four patients required a colectomy and 20 others died directly from C. difficile colitis. Twenty-two percent had a prior history of C. difficile colitis. A recent surgical procedure and immunosuppression were common predisposing conditions. Lung transplant patients were 46 times more likely to have C. difficile colitis and eight times more likely to have severe disease. Abdominal computed tomography scan correctly diagnosed all patients, whereas 12.5% of toxin assays and 10% of endoscopies were falsely negative. Patients undergoing colectomy for C. difficile colitis had an overall death rate of 57%. Significant predictors of death after colectomy were preoperative vasopressor requirements and age. ConclusionsC. difficile colitis is a significant and increasing cause of death. Surgical treatment of C. difficile colitis has a high death rate once the fulminant expression of the disease is present.

The dendritic cell and human cancer vaccines.

Over the past ten years, the identification of the critical role that dendritic cells (DCs) play in stimulating a specific immune response has led to their use in cancer and HIV therapy. Interesting responses have been reported but the most effective approach and the duration of these responses are still unclear. The quality of DCs, the means by which tumor antigens are delivered to DCs and the problems associated with monitoring the immune response have made individual studies difficult to compare. Much work is still needed to determine the role that DC-based cancer vaccines will have, the most effective way to deliver DCs to patients and the most relevant antigens to provide to DCs.

Results of Laparoscopic Gastric Bypass in Patients with Cirrhosis

Background: The safety and efficacy of bariatric surgery in patients with cirrhosis has not been well studied. Methods: A retrospective review was conducted of patients with cirrhosis who underwent weight-loss surgery at a single institution. Results: Out of a total of 2,119 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), 30 patients (1.4%) with cirrhosis were identified.When compared with the entire cohort, patients with cirrhosis were significantly more prone to be heavier (BMI 53 vs 48), older in years (age 50 vs 45), more likely to be male (RR=1.3), and have a higher incidence of diabetes (70% vs 21%) and hypertension (67% vs 21%), P<0.05. The diagnosis of cirrhosis was made intra-operatively in 90% of patients. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. Early complications occurred in 9 patients and included anastomotic leak (1), acute tubular necrosis (4), prolonged intubation (2), ileus (1), and blood transfusion (2). Mean length of hospital stay was 4 days (2-18). There was one late unrelated death and one patient with prolonged nausea and protein malnutrition. The average follow-up time was 16 months (1-48). For patients >12 months postoperatively (n=15), the average percent excess weight loss was 63±15%. Conclusion: Laparoscopic RYGBP in the cirrhotic patient has an acceptable complication rate and achieves satisfactory early weight loss. Patients tend to be heavier, older, male and more likely to have diabetes and hypertension. Long-term studies are necessary to examine how weight loss impacts established cirrhosis.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred

Background: There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery. Methods: Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included. Results: The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration. Conclusion: Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

The Orientation of the Antecolic Roux Limb Markedly Affects the Incidence of Internal Hernias after Laparoscopic Gastric Bypass

Background: Internal herniation of the bowel may be a late complication after the laparoscopic Roux-en-Y gastric bypass (RYGBP). A seemingly minor change in technique is described that significantly prevents herniation behind the Roux limb mesentery. We hypothesized that internal hernias behind the Roux limb mesentery occur more frequently when the Roux limb is oriented such that the distal tip is toward the lesser curvature of the gastric pouch with the bowel then curving to the patients left, compared with the opposite orientation. Methods: A retrospective chart review was performed of our prospectively collected database. A change in surgical technique occurred June 2003, in an attempt to reduce internal hernia formation. We compared 200 consecutive antecolic left-oriented RYGBP operations performed immediately previous to June 2003 (Group A) with 200 consecutive antecolic right-oriented RYGBP operations performed after June 2003 (Group B). Results: There was an 9.0% rate of internal hernia formation in Group A (18/200) and a 0.5% rate of internal hernia formation in Group B. Internal hernias were repaired an average of 1.2 years after surgery (range 4–30 months, median 14.3 months). The average length of follow-up was 2.1 and 1.6 years in Groups A and B, respectively. All herniations were behind the Roux limb mesentery. The difference in hernia formation after the change in technique was significant (P<0.005). Conclusions: With a simple change in technique, the incidence of internal herniation behind the Roux limb mesentery may be significantly reduced or eliminated.

Sexual Dysfunction Is Common in the Morbidly Obese Male and Improves after Gastric Bypass Surgery

BACKGROUND There has been limited research examining the mechanisms and epidemiology of sexual dysfunction in the morbidly obese. Our objectives were to measure sexual function in the morbidly obese man before and after substantial weight loss induced by gastric bypass surgery. STUDY DESIGN All male patients in undergoing gastric bypass completed the Brief Male Sexual Function Inventory (BSFI) before and after operation. BSFI scores were also compared with published normative controls and analyzed for predictors of change. Mixed models were created to control for age, diabetes, and hypertension. RESULTS Ninety-seven men with a mean age of 48 years (range 19 to 75 years) and mean body mass index of 51 kg/m(2) (range 36 to 89 kg/m(2)) underwent gastric bypass surgery. On average, preoperative morbidly obese patients reported a substantially greater degree of sexual dysfunction than did published reference controls in all domains, p < 0.001. Increasing weight independently predicted lower domain scores. Mean postoperative followup length was 19 months (range 6 to 45 months). On average, BSFI scores improved from preoperative levels by bivariate analysis in all categories (means+/-SE): sexual drive (range 0 to 8), 3.9+/-0.3 to 5.3+/-0.3; erectile function (range 0 to 12), 6.4+/-0.5 to 8.9+/-0.5; ejaculatory function (range 0 to 8), 4.9+/-0.4 to 6.3+/-0.4; problem assessment (range 0 to 12), 7.4+/-0.5 to 9.6+/-0.5; and sexual satisfaction (range 0 to 4), 1.6+/-0.2 to 2.3+/-0.2; all p < 0.01. On multivariable analysis, the amount of weight loss independently predicted the degree of improvement in all BSFI domains, p < 0.05. After an average 67% excess weight loss, BSFI scores in postoperative gastric bypass patients approached those of the reference controls. CONCLUSIONS Men with morbid obesity commonly suffer from profound, but reversible sexual dysfunction.

Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary

BackgroundThe routine use of closed suction drains and upper GI (UGI) series has been used to aid in the diagnosis and management of gastrojejunal leak after gastric bypass as well as diagnose intra-abdominal bleeding.Materials and Methods352 consecutive laparoscopic gastric bypass procedures were performed without the use of routine drains or post-operative UGI series.ResultsThere were no adverse events related the lack of routine drains or UGI studies. Five patients (1.4%) did have a drain placed at the time of surgery, at the surgeon’s discretion, due to a particularly difficult gastrojejunal anastomosis although none developed an anastomotic leak. UGI series were ordered post-operatively in seven patients all for unexplained tachycardia, none of who had abnormal radiographic findings. Two patients with tachycardia and normal UGIs had a negative diagnostic laparoscopy to rule out a leak. No UGI series demonstrated a leak although one tachycardic patient with a normal UGI did have a leak diagnosed at laparoscopy. Five patients had clinical signs of a severe gastrojejunal obstruction. Three resolved completely within 48 hours, and two patients required endoscopic intervention without the need for UGI. Six patients (1.7%) required a blood transfusion; all developed tachycardia and five were from bleeding in the GI tract.ConclusionsRoutine use of drains and UGI series were not necessary for the safe management of gastric bypass patient in our series. In this small series, clinical indicators for leak, obstruction or bleeding were obvious without the additional data from a drain or UGI.

Superior Mesenteric Artery Syndrome after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.

Management of ventral hernias during laparoscopic gastric bypass

BACKGROUND Despite the relatively high incidence of ventral hernias in the morbidly obese, their management in bariatric surgery patients remains difficult and controversial. We sought to define a rational approach to ventral hernia management in the gastric bypass patient in a university hospital setting. METHODS We performed a retrospective, single-institution analysis of all patients who had undergone concomitant ventral hernia repair (VHR) during antecolic gastric bypass. RESULTS A total of 325 consecutive patients underwent laparoscopic gastric bypass, and 26 (8%) had a ventral hernia found at laparoscopic gastric bypass. In 8 select patients, the incarcerated omental hernia contents were left in situ, and their VHR was successfully deferred. Of the remaining 15 patients, 8 underwent primary VHR and 10 underwent VHR with prosthetic mesh (Proceed). The average length of hospital stay for the VHR versus non-VHR repair groups was 1.6 and 2.7 days, respectively. The only predictor for an increased length of hospital stay was hernia repair with mesh (odds ratio 9.2, P = .002). The average follow-up was 14 months (range 4-30 months). Of the 8 patients who had undergone primary repair, 2 presented with a postoperative small bowel obstruction at the site of their VHR. None of the patients who underwent VHR with prosthetic mesh developed an obstruction or clinical evidence of recurrence or infection. CONCLUSION In this small study, primary VHR was associated with a high incidence of small bowel obstruction. Prosthetic mesh repair of ventral hernias during LGB did not result in any infection, although the length of hospital stay was increased. In select patients, deferral might be safe.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

BackgroundThis study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons.MethodsFrom October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants.ResultsResponses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10–150 cases) are needed for a claim of proficiency.ConclusionLaparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.