Rob Schuster

Concurrent Gastric Bypass and Repair of Anterior Abdominal Wall Hernias

Background: Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair. Methods: All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed. Results: 12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 ± 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 ± 10.3 kg/m2 (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 ± 13.4 cm2. One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 ± 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs. Conclusion: Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.

Intra-operative Fluid Volume Influences Postoperative Nausea and Vomiting after Laparoscopic Gastric Bypass Surgery

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a commonly performed operation for morbid obesity. A significant number of patients experience postoperative nausea and vomiting (PONV) following this procedure. The aim of this study was to determine the effect, if any, of intra-operative fluid replacement on PONV. Methods: Patients who underwent laparoscopic (RYGBP) for morbid obesity during a 12-month period were included in this retrospective analysis. Demographic data including age, gender, and body mass index (BMI) were collected. Perioperative data also included total volume of intra-operative fluids administered, rate of administration, urine output, length of surgery, and incidence of PONV as determined by nursing or anesthesia records in the postanesthesia care unit (PACU). Data were analyzed by t-test. Results: The table below depicts demographic and perioperative data, comparing patients who experienced PONV (n=125) in the PACU with those who did not (n=55). Values are mean ± standard deviation. Conclusions: PONV is a common complication after laparoscopic RYGB. Patient who did not experience PONV received a larger volume of intravenous fluid at a faster rate than similar patients who complained of PONV.

Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient.

BackgroundEsophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique.MethodsAll patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions.ResultsThe study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44–63 years) and an average body mass index (BMI) of 47 kg/m2 (range, 38–69 kg/m2). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum’s second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%).ConclusionTransnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.