Sergio Susmallian

Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue

In 50 morbidly obese patients, we quantified the soft tissue of the neck from the skin to the anterior aspect of the trachea at the vocal cords using ultrasound. Thyromental distance, mouth opening, limited neck mobility, modified Mallampati score, abnormal upper teeth, neck circumference and sleep apnoea were assessed as predictors of difficult laryngoscopy. Of the nine (18%) cases of difficult laryngoscopy, seven (78%) had a history of obstructive sleep apnoea, compared with two of the 41 patients (5%) in whom laryngoscopy was easy (p < 0.001). Patients in whom laryngoscopy was difficult had more pretracheal soft tissue (mean (SD) 28 (2.7) mm vs. 17.5 (1.8) mm; p < 0.001) and a greater neck circumference (50 (3.8) vs. 43.5 (2.2) cm; p < 0.001). None of the other predictors correlated with difficult laryngoscopy. We conclude that an abundance of pretracheal soft tissue at the level of the vocal cords is a good predictor of difficult laryngoscopy in obese patients.

Seroma after laparoscopic repair of hernia with PTFE patch : is it really a complication?

Abstract.We evaluated the true incidence of seroma formation after laparoscopic repair of incisional hernia with polytetrafluoroethylene (PTFE) patch. In a prospective study, 20 patients who underwent laparoscopic repair of incisional hernia with PTFE were evaluated clinically and with ultrasound examination for seroma formation up to the 90th postoperative day. Seroma was diagnosed clinically in only 35% of cases, while ultrasound examination revealed the presence of seroma in 100% of patients. Ultrasound examination is a reliable tool for diagnosis of early or delayed postoperative seroma formation following laparoscopic repair of incisional hernia with Gore-Tex Dualmesh.

Topical Nifedipine vs. Topical Glyceryl Trinitrate for Treatment of Chronic Anal Fissure

AbstractPURPOSE: Nifedipine (administered orally or applied topically) has been effective for nonsurgical treatment of anal fissure. We compared the efficacy of nifedipine vs. glyceryl trinitrate for chemical sphincterotomy of anal fissure. METHODS: In a prospective, double-blind trial, 52 patients suffering from chronic anal fissure were randomly and equally allocated to receive either glyceryl trinitrate or nifedipine, both applied topically to the perianal region. The end point of the study was healing within a predetermined period (6 months). Variables assessed included demographic data (age, gender), symptoms associated with the fissure, duration of treatment, percentage of healing, untoward effects of treatment, pain scores, duration of follow-up, recurrence, and need for complementary means of treatment. Descriptive data are presented as mean ± standard deviation and quantal data as percentage. Inference analysis was performed using the Student’s t-test for the descriptive data and the chi-squared or Fisher’s exact test for nominal variables. RESULTS: No significant differences were recorded with regard to age, gender, symptoms associated with the fissure, or duration of treatment. Healing rate was higher (P < 0.04) with nifedipine (89 percent) as compared with glyceryl trinitrate (58 percent). Treatment side effects (headache, flushing) were more frequent (P < 0.01) with glyceryl trinitrate (40 percent) as compared with nifedipine (5 percent). Pain scores were significantly lower (P < 0.03) on completion of treatment in both groups (3.2 in glyceryl trinitrate and 3.4 in nifedipine vs. 6.2 and 6.1, respectively), but did not differ between the two groups. Recurrence occurred in 31 percent of patients treated with glyceryl trinitrate and 42 percent of those treated with nifedipine after a mean period of 18 ± 3 weeks and 12 ± 4 weeks, respectively. CONCLUSION: Topical application of nifedipine for management of chronic anal fissure was more effective and had fewer side effects than topical glyceryl trinitrate. Recurrence was frequent with both drugs.

Perforation of the terminal ileum induced by blast injury: delayed diagnosis or delayed perforation?

Blast injuries are rare, and although blast-induced perforations of the bowel have been described in the past, the entity of a delayed perforation caused by an evolving injury has not been reported. We report three men injured by the explosion of a terrorist bombing in open air. They suffered primary blast injuries, which resulted in isolated perforations of the terminal ileum. They were operated at different times after the blast event. The resected specimens were examined under light microscopy. One patient was operated immediately, and had three perforations in the terminal ileum. In the other two patients, abdominal complaints appeared only 24 and 48 hours later. These two patients were found to have hematomas in the wall of the terminal ileum, and small perforations therein, with almost no contamination of the peritoneal cavity. On histological examination, there were small perforations with disruption of all intestinal layers. In the vicinity of the perforations, the mucosa was necrotic and disorganized. The submucosa showed edema and vascular thrombi, and at several points mucus was shown dissecting through the muscularis propria, thus creating minute microperforations. Because of the findings in these patients, we suggest a mechanism of evolving damage to the bowel wall and delayed perforation rather than delayed diagnosis, after blast injuries. We suggest that patients exposed to a significant blast should be watched carefully for at least 48 hours.

Access-Port Complications after Laparoscopic Gastric Banding

Background: The aim of this retrospective study was to identify complications related to the access-port, after Lap-Band® system placement by laparoscopy. Methods: The records of 333 morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB) were reviewed for the overall surgical complications. Data was further analyzed regarding the complications related to the access-port. Results: From January 1999 to December 2001, the overall complication-rate with the LAGB was 25.8%. 45 complications (13.5%) were related to the accessport in 34 patients following LAGB placement.The 45 access-port complications were distributed as follows: infection 51.1%, tubing disconnection 17.7%, dislodgment of the access-port 15.6%, leak of the reservoir 11.1%, and skin ulceration by the port 4.45%. Conclusion: The integrity of the Lap-Band® system is essential to achieve the objective of the operation: weight loss. Complications related to the access-port were relatively frequent, but preventable.

Laparoscopic repair of access port site hernia after Lap-Band® system implantation

Background: The appearance of hernia around the access port site after implantation of a laparoscopic adjustable gastric band (LAGB) is a complication that can limit the beneficial effect of the device. We evaluated the incidence of hernias at the port-site for band adjustment and propose a technique for its repair. Methods: A retrospective study was conducted of 459 patients who underwent LAGB system implantation for treatment of morbid obesity between January 1999 and July 2001.We recorded all complications that occurred following LAGB placement, with special emphasis on port site hernia. Results: 3 out of the 459 patients (0.65%) had a hernia at the site where the reservoir had been implanted. The use of a trocar >11 mm should be avoided to prevent this complication. We describe our technique of repair of the hernia by intraperitoneal detachment and pulling of the access reservoir into the peritoneal cavity, intraperitoneal repair of the defect with Gore-Tex® Dual mesh, and reimplantation of the reservoir. Conclusions: Our technique successfully repaired the hernia, and enabled continuation of adjustments to the gastric band.

Obturator hernia as a frequent finding during laparoscopic pelvic exploration: A retrospective observational study.

AbstractHernia through the obturator canal is usually unsuspected and hence undiagnosed. Patients with obturator hernias present as acute cases of intestinal obstruction secondary to strangulation or incarceration, with high rate of morbidity and mortality due to delayed diagnosis and treatment. The know incidence of obturator hernia is low, representing 0.073% (11 of 15,098) of all hernias repaired at the Mayo Clinic in a retrospective study of 15 years. In this study, we conducted a retrospective analysis of laparoscopic extraperitoneal hernia repairs that were performed between the years 2003 and 2007. All procedures were undertaken by 2 experienced surgeons who performed more than 150 previous surgeries. In 293 patients who underwent repair of bilateral or recurrent inguinal hernia, exploration of the obturator foramen was conducted looking for obturator hernia, which was found in 20 cases (6.82% of patients). The true incidence of obturator hernia is greater than that reported in the literature, and the chances of detecting hernia are greater if an equal number of men and women are scanned could be higher if pelvic scanning was performed.

Dynamic Radioisotope Scintigraphy for Gastric Banding Adjustment

Background: Gastric banding is today a common restrictive procedure to treat morbid obesity. After operation, adjustment of the band is required to adequately restrict food intake, allowing better results. The aim of this study was to evaluate the results of a unique method of adjustment using dynamic radioisotope scintigraphy. Methods: 40 patients after Laparoscopic Adjustable Gastric Banding (LAGB) were prospectively divided into 2 equal groups, and the results of adjustment analyzed using the conventional method of fluoroscopic image and barium swallow (FA Group), and our proposed new method of dynamic radioisotope scintigraphy (DRS Group) using Tc99-phytate labeled plain yogurt. Results: After 6 months follow-up, the FA group lost 12.34%, while the DRS group lost 20.34% of their initial weight. In the FA group, we found that 95% of the patients needed re-adjustments versus only 25% in the DRS group (P <0.0001). Vomiting was more frequent in the FA group than in the DRS group, mean 0.65 and 0.2, respectively (P < 0.009). The radiation exposure was 4 times higher in the FA group, but the cost of the 2 adjustment procedures was similar. Conclusion: DRS is a more physiologically friendly and accurate method of gastric banding adjustment than the conventional barium swallow adjustment; it also results in a better weight loss during the first 6 months after operation.