Rodrigo Gonzalez

Anastomotic leaks after laparoscopic gastric bypass.

The gastrojejunostomy may be the most technically challenging step when performing laparoscopic Roux-en-Y gastric bypass. Patients who develop anastomotic leaks have increased morbidity and mortality rates. Difficulty in diagnosis is related to nonspecific systemic symptoms and limitations in most radiological studies. Our aim is to evaluate the incidence, etiology, diagnosis, management, and prevention of anastomotic leaks occurring in patients undergoing laparoscopic Roux-en-Y gastric bypass.

Relationship Between Tissue Ingrowth and Mesh Contraction

Contraction is a well-documented phenomenon occurring within two months of mesh implantation. Its etiology is unknown, but it is suggested to occur as a result of inadequate tissue ingrowth into the mesh and has been associated with hernia recurrence. In continuation of our previous studies, we compared tissue ingrowth characteristics of large patches of polyester (PE) and heavyweight polypropylene (PP) and their effect on mesh contraction. The materials used were eight PE and eight PP meshes measuring 10 × 10 cm2. After random assignment to the implantation sites, the meshes were fixed to the abdominal wall fascia of swine using interrupted polypropylene sutures. A necropsy was performed three months after surgery for evaluation of mesh contraction/shrinkage. Using a tensiometer, tissue ingrowth was assessed by measuring the force necessary to detach the mesh from the fascia. Histologic analysis included inflammatory and fibroblastic reactions, scored on a 0–4 point scale. One swine developed a severe wound infection that involved two PP meshes and was therefore excluded from the study. The mean area covered by the PE meshes (87 ± 7 cm2) was significantly larger than the area covered by the PP meshes (67 ± 14 cm2) (p = 0.006). Tissue ingrowth force of the PE meshes (194 ± 37 N) had a trend toward being higher than that of the PP meshes (159 ± 43 N), although it did not reach statistical significance. There was no difference in histologic inflammatory and fibroblastic reactions between mesh types. There was a significant correlation between tissue ingrowth force and mesh size (p = 0.03, 95% CI: 0.05–0.84). Our results confirm those from previous studies in that mesh materials undergo significant contraction after suture fixation to the fascia. PE resulted in less contraction than polypropylene. A strong integration of the mesh into the tissue helps prevent this phenomenon, which is evidenced by a significant correlation between tissue ingrowth force and mesh size.

Laparoscopic vs open resection for the treatment of diverticular disease

Introduction: The aim of this study was to evaluate whether laparoscopic colon resection (LCR) offers any advantages over open colon resection (OCR) in the treatment of diverticular disease. Methods: Between 1992 and 2002, 95 patients underwent LCR and 80 patients underwent OCR for the treatment of diverticular disease. Demographics, details of operative procedure, outcome, and pathology were compared. Results: Patients in both groups were matched for age, sex, body mass index, history of previous abdominal operations, comorbidities, location of the disease, and presence of complications. LCR resulted in significantly less estimated blood loss and postoperative complications, shorter time to first bowel movement, and shorter length of stay than the OCR. There was no difference in operative time, intraoperative complications, mortality rates between groups. Conclusions: LCR is a safe and effective approach for the treatment of patients with diverticular disease. It results in less estimated blood loss, shorter time to first bowel movement, less postoperative complications, and shorter length of hospital stay.

Consequences of Conversion in Laparoscopic Colorectal Surgery

IntroductionLaparoscopic procedures converted to open approaches have been associated with higher complication rates than laparoscopic and open cholecystectomy and appendectomy. Laparoscopic colorectal resections have relatively high conversion rates compared with other laparoscopic procedures. This study was designed to evaluate outcomes of conversions compared with laparoscopic and open colorectal resections.MethodsWe reviewed 498 consecutive colorectal resections performed between 1995 and 2002. Procedures were divided into laparoscopic colorectal resections, open colorectal resections, or conversions. Demographics, underlying disease, type of procedure performed, and operative outcomes were compared between groups.ResultsOf the 238 laparoscopic procedures performed, 182 were completed laparoscopically and 56 (23 percent) required conversion; 260 were performed open. Conversions were associated with greater blood loss (200 (range, 50–750) vs. 100 (range, 30–900) ml), longer time to first bowel movement (82 (range, 40–504) vs. 72 (range, 12–420) hr), and longer length of stay (6 (range, 2–67) vs.. 5 (range, 2–62) days) than the laparoscopic colorectal resections group. There was no difference in operative time, transfusion requirements, intraoperative and postoperative complications, or mortality between conversions and laparoscopic colorectal resections. Conversions resulted in fewer patients requiring transfusions (4 vs. 14 percent), shorter time to first bowel movement (82 (range, 40–504) vs. 93 (range, 24–240) hr), and shorter length of stay (6 (range, 2–67) vs. 7 (range, 2–180) days) than in the open colorectal resections group. There were no differences in complications or mortality between the conversion group and the open colorectal resections group.ConclusionsLaparoscopic colorectal resections has a relatively high conversion rate; however, the converted cases have outcomes similar to open colorectal resections. In fact, the converted group required fewer blood transfusions than the open group. Experience and good judgment are fundamental for timely conversion of a laparoscopic procedure to open to decrease complication rates. Despite a high conversion rate, surgeons should consider laparoscopic colorectal resections, because even when necessary, conversion does not result in poorer outcomes than laparoscopic colorectal resections or open colorectal resections.

Extensive preoperative testing is not necessary in morbidly obese patients undergoing gastric bypass.

Morbidly obese patients are considered at high risk for perioperative complications and often undergo extensive testing for preoperative clearance. We analyzed prospectively collected data from 193 patients undergoing weight loss surgery between November 2000 and November 2002. Preoperative chest x-ray examination, pulmonary function tests, noninvasive cardiac testing, and blood work were performed routinely. Preoperative testing identified abnormalities on eight chest x-ray films (4%) and 29 electrocardiograms (15%), none of which required preoperative intervention. Spirometry was abnormal in 41 patients (21%); logistic regression identified preexisting asthma as predictive of obstructive physiology (odds ratio [OR] 3.3; 95% confidence interval [CI] 1.2 to 8.9), and body mass index as predictive of restrictive physiology (OR 1.1; 95% CI 1.01 to 1.2). Arterial blood gases identified only one case of severe hypoxemia requiring intervention. Mild hypoxemia was associated with increasing age (OR 14.5; 95% CI 1.8 to 114). Echocardiography demonstrated four abnormalities (2%); previous history of cardiac disease was the only risk factor (OR 14.5; 95% CI 1.8 to 114). Complete blood count did not identify 84% and 50% of the patients with iron (n = 31) and vitamin B12 (n = 12) deficiencies, respectively. Age, body mass index, and history of asthma were associated with abnormal pulmonary function tests and previous cardiac disease with abnormal cardiac testing. These tests are not mandatory as a routine preoperative evaluation and can be used selectively on the basis of medical history.

Preoperative factors predictive of complicated postoperative management after Roux-en-Y gastric bypass for morbid obesity

Introduction: This study was undertaken to determine preoperative predictive factors of complicated postoperative management after Roux-en-Y gastric bypass (RYGB) for morbid obesity.Methods: Between January 1999 and January 2002, 158 patients who underwent a RYGB received a standardized preoperative evaluation and data were collected prospectively. Complicated postoperative management was defined as patients requiring postoperative ICU admission for ≥48 h, or those needing transfer from the floor to the ICU. Patients with complicated management were compared with those in whom ICU admission was not necessary.Results: Twenty-three patients (14.5%) required prolonged ICU admission (mean stay of 6.3 ± 1.7 days). After multivariate analysis, body mass index (BMI) >50 kg/m2, forced expiratory volume (FEV1) <80% predicted, previous abdominal surgeries, and abnormal EKG were found to be independently associated with an increased likelihood of complicated postoperative care.Conclusion: BMI >50 kg/m2, FEV1 <80% predicted, previous abdominal surgeries, and abnormal EKG increase the likelihood of complicated postoperative management after RYGB for morbid obesity.

Does establishing a bariatric surgery fellowship training program influence operative outcomes

BackgroundRoux-en-Y gastric bypass (RYGB) has a long learning curve that may be reflected in operative outcomes. This study sought to assess whether training a fellow has an impact on the operative outcomes of the training program.MethodsProspectively collected data on 150 consecutive patients were compared before (group 1) and after (group 2) establishment of a fellowship-training program.ResultsA greater number of patients underwent laparoscopic RYGB (LRYGB) in group 2 than in group 1 (63% vs 46%; p = 0.01). The group 2 patients were similar to the group 1 patients in terms of age, gender, length of stay, and complication rate. However, they had a higher body mass index (BMI) (median 50 kg/m2; range, 39–64 kg/m2 vs median, 46 kg/m2; range, 38–56 kg/m2; p = 0.01) and a higher incidence of prior abdominal procedures (21% vs 7%; p = 0.006). In addition, operative time was significantly shorter for the patients who underwent open RYGB (ORYGB) (median, 150 min; range, 65–280 min vs median, 110 min; range, 50–210 min; p < 0.001) and LRYGB (median, 202 min; range, 105–450 min vs median, 134 min; range, 50–191 min; p < 0.001) in group 2 than for the patients in group 1. The patients who underwent ORYGB in groups 1 and 2 had similar characteristics and outcomes. Increasing experience with both ORYGB and LRYGB correlated with a decrease in operative times for group 2 (p < 0.001), but not for group 1.ConclusionEstablishment of a fellowship program shortens the operative times for both open and laparoscopic RYGB and expands the scope of bariatric practice by compounding the experience of the operating team without increasing complications.

Does experience preclude leaks in laparoscopic gastric bypass

BackgroundImproved outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) have been demonstrated once pratice has moved beyond the learning curve. However, there is no evidence that experience has a favorable impact on the incidence of leaks. This study evaluated the incidence of staple-line leaks as experience accrued in a university-based bariatric surgery program.MethodsProspectively collected data on our first 200 patients undergoing LRYGB since July 1998 were analyzed. Linear staplers were used to divide the stomach and to create a side-to-side jejunojejunostomy. A side-to-side cardiojejunostomy was created using a 21-mm circular stapler. Patient characteristics, operative data, and outcomes were evaluated chronologically with comparison of outcomes between quartiles.ResultsStaple-line leaks developed in 9 (4.5%) of the first 200 patients undergoing LRYGB. Among the 200 patients were 190 women (95%). The median age of the patients was 48 years (ranges, 24–62 years), and their body mass index was 43 kg/m2 (ranges, 32–59 kg/m2). As surgeons’ experience increased over time, there was a significant increase in the weight of patients and the percentage of patients with previous abdominal operations. There also was a significant decrease in conversion rates and operative times. Leaks occurred in six patients at the cardiojejunostomy (3%), in two patients jejunojejunostomy (1%), and in one patient at the excluded stomach (0.5%). Of the 50 leaks that occurred in each quartile, there were in the 3 in the 1st quartile, 1 in the 2nd quartile, 2 in the 3rd quartile, 3 in the 4th quartile. The differences were not significant. There was no correlation between the number of LRYGBs, and the occurrence of a leak (p = 0.59 confidence interval −0.13–0.22).ConclusionsThe incidence of staple-line leaks appears to be independent of the number of LRYGBs performed. These data suggest that surgeons’ experience may not eliminate anastomotic complications experienced by patients undergoing LRYGB.

Absorbable Versus Nonabsorbable Mesh Repair of Congenital Diaphragmatic Hernias in a Growing Animal Model

INTRODUCTION The repair of large congenital diaphragmatic hernia frequently results in patch disruption and recurrence as patients grow in size. Absorbable meshes allow for ingrowth of endogenous tissue as they are degraded, providing a more natural and durable repair. The aim of this study was to compare the characteristics of the new diaphragmatic tissue between an absorbable biologic mesh and a nonabsorbable mesh for repairing diaphragmatic hernia in a growing animal model. METHODS The left hemi-diaphragm of twenty 2-month-old Yucatan pigs was nearly completely resected. Small intestinal submucosa (SIS; Cook Biotech, Lafayette, IN) and expanded polytetrafluoroethylene (ePTFE; W.L. Gore & Associates, Flagstaff, AZ) were randomly assigned to cover the defect in 10 animals each, and were survived for 6 months. During necropsy, newly formed diaphragmatic tissue was evaluated and compared between the two groups. RESULTS At necropsy, the animals had tripled their weight. Patch disruption and herniation occurred in 3 animals in the ePTFE group and none in the SIS group. The SIS mesh had better integration to the chest wall (2.8 ± 0.2 versus 1.3 ± 0.3), more muscle growth within the newly formed diaphragmatic tissue (1.9 ± 0.2 versus 0.4 ± 0.2), and less fibrotic tissue (2.1 ± 0.5 versus 3.4 ± 0.4) than ePTFE. There was no difference between SIS and ePTFE in terms of adhesion scores to the lung (2 ± 0.4 versus 2.4 ± 0.4) and liver (1.8 ± 0.3 versus 2.2 ± 0.5). CONCLUSION SIS allows for tissue ingrowth from surrounding tissue as it degrades, providing a more durable repair with 30% less incidence of herniation in a porcine model. As the diaphragm grows, SIS resulted in a more natural repair of the defect with more tissue growth, better tissue integration, and a comparable adhesion formation to ePTFE.

Management of Incidental Ovarian Tumors in Patients Undergoing Gastric Bypass

Background: Ovarian disease is common in obese women and is usually not screened during routine preoperative evaluation in patients undergoing bariatric surgery. Consequently, surgeons may encounter previously undiagnosed adnexal tumors during bariatric operations. The aim of this study is to report our experience with incidental ovarian tumors in patients during Roux-en-Y gastric bypass (RYGBP). Methods: Prospectively collected data on all consecutive patients undergoing RYGBP for clinically significant obesity from July 1998 to September 2003 were reviewed for patients with incidental gynecological tumors. Details of operative treatment and outcomes are reported herein. Results: 460 women underwent RYGBP during the study period. 52 (11%) had a previous hysterectomy and/or bilateral oophorectomy and were excluded from the study. 12 ovarian masses, median tumor size 11 cm (range 4-65 cm) were found in 10 women (2.5%) during 6 open and 4 laparoscopic RYGBPs. Mean age was 40±9 years and mean BMI was 58±12 kg/m2. Resection of 9 benign cystic lesions and 2 malignant lesions was undertaken. One patient with polycystic ovary syndrome did not undergo resection. The RYGBP was completed in all but 2 patients who, by appearance and intraoperative frozen biopsy, had evidence of malignancy. No additional morbidity resulted from the added gynecological procedure. Based on these results, an algorithm for the treatment of incidental gynecological tumors is suggested. Conclusions: Although infrequent, incidental ovarian tumors may be discovered in patients undergoing bariatric surgery, emphasizing the importance of thorough exploration of the abdominal cavity. Consultation with a gynecologist is warranted in most instances, and treatment should be on a patient-by-patient basis, especially in women of child-bearing age.