Shankar R. Raman

Well leg compartment syndrome after robotic prostatectomy: a word of caution

Compartment syndrome of the lower extremity is a rare complication that can occur following prolonged surgery in the lithotomy position. We report the case of a 45-year-old man who developed compartment syndrome in the post-operative period after radical robotic prostatectomy. Four-compartment fasciotomy helped prevent serious sequelae from the injury. Young males with a high body mass index undergoing prolonged surgery in the lithotomy position are particularly at risk for developing this complication. The early diagnosis and implementation of preventive measures will facilitate timely management.

Does transumbilical single incision laparoscopic adjustable gastric banding result in decreased pain medicine use? A case-matched study

BACKGROUND We report on our initial experience of laparoscopic adjustable gastric banding performed through a single transumbilical incision of approximately 2.5 cm. All single incision bands were placed using the Covidien SILS Port™ and the Allergan Lap-Band(®). The purpose of the present study was to report on the analgesic use after single-incision laparoscopic surgery (SILS) adjustable gastric banding versus that after conventional laparoscopic gastric banding at a community hospital. METHODS A retrospective review of postoperative pain medication use and the time to return to work was conducted of 24 consecutive SILS adjustable gastric banding procedures compared with 24 traditional 5-incision laparoscopic adjustable gastric banding procedures. RESULTS The patients in both groups were evenly matched for age, body mass index, and co-morbidities. All patients were discharged home on postoperative day 1. No complications developed. The mean patient-controlled analgesia morphine use during hospitalization for the SILS group was 33 ± 19.22 mg versus 49 ± 23.78 mg in the traditional group (P <.05). The mean period of postoperative pain medication use for the SILS group was 2 days versus 5 days for the traditional group (P <.05). However, the mean period to return to work was 9.5 days for the SILS group versus 11 days for the traditional group (P = NS). CONCLUSION Transumbilical single-incision laparoscopic adjustable gastric banding with mechanical port fixation resulted in significantly decreased postoperative pain medication use compared with traditional laparoscopic gastric banding with suture fixation of the band port. Also, the patients tended to return to work earlier after SILS gastric banding.

Endolumenal revision obesity surgery results in weight loss and closure of gastric-gastric fistula

BACKGROUND Approximately 20-50% of patients regain weight 3-5 years after Roux-en-Y gastric bypass (RYGB) surgery. Gastric-gastric fistulas and dilation of the gastrojejunostomy and gastric pouch have been reported in these patients. Traditional revision surgery after RYGB has greater morbidity and mortality compared with the index bariatric procedure. We studied our initial results with revision of obesity surgery using an endoscopic platform in a community hospital setting. METHODS A retrospective review was performed of patients who had undergone this endoscopic revisional procedure secondary to significant weight regain with or without gastric-gastric fistula. All patients underwent revision of the gastrojejunostomy and/or closure of the gastric-gastric fistula using this minimally invasive approach. RESULTS A total of 37 consecutive patients (36 women) with a mean age of 45 years and mean weight regain of 15.1 ± 10.0 kg were included in the present study. The mean interval between RYGB and revision was 5.2 years (range 1-11). The mean preoperative and postoperative stomal size was 21.5 and 10 mm, respectively. Anchors were successfully placed in all patients. The mean follow-up period was 4.69 months (range 2-10). The mean percentage of excess body weight loss was 23.5% ± 66.4%. No immediate complications developed. Two patients underwent endoscopic dilation of the stoma because of persistent meal intolerance. Three gastric-gastric fistulas were successfully closed. CONCLUSION Revision of gastrojejunostomy after RYGB can be safely undertaken using this endoscopic platform. The short-term follow-up results showed clinically significant weight loss. Long-term follow-up is needed. Closure of gastric-gastric fistulas can also be achieved using this procedure.

Emergency Subtotal Colectomy in a Jehovah’s Witness With Massive Lower Gastrointestinal Bleeding: Challenges Encountered and Lessons Learned

A 66-year-old woman who was a Jehovahs Witness had massive lower gastrointestinal bleeding and subsequent hypovolemic shock, necessitating a subtotal colectomy. During the postoperative period, her hemoglobin level decreased to a low of 2.6 g/dL, prolonging her dependence on mechanical ventilation. Prudent perioperative care resulted in a successful outcome. Blood-conserving techniques are indispensable in the management of Jehovahs Witnesses who have massive blood loss. Maximizing oxygen transport, minimizing blood loss, using a cell saver when permissible, providing optimal ventilatory support, performing tracheostomy early if prolonged mechanical ventilation is expected, and augmenting hemoglobin production with administration of iron and erythropoietin are techniques that can facilitate successful outcome in patients who refuse blood transfusion.

Magnetic resonance angiography unmasks frostbite injury

A 50-year-old homeless man presented to the emergency room with complaints of blisters in both feet after exposure to subzero temperatures. Physical examination showed blisters with mottling of both feet extending up to the …

Colocutaneous fistula after suction lipoplasty: case report and literature review.

Suction lipoplasty is considered to be a relatively safe procedure but is not without complications, some of which are lethal. Colonic injury after liposuction has not been reported so far, although small intestinal perforations are known to occur. We present a case of colocutaneous fistula after suction lipoplasty that was successfully managed nonoperatively. A 56-year-old man with history of abdominoplasty presented with feculent discharge from the abdominal wall 7 days after liposuction. A computed tomography scan of the abdomen showed free intraperitoneal air, with a suspected transverse colonic fistula to the skin. After drainage of abdominal wall abscess, he recovered and the fistula spontaneously closed. Abdominal wall hernias, abdominal operations, and immunosuppression are risk factors for abdominal and intestinal perforations after lipoplasty. Low output colocutaneous fistulae after lipoplasty may close spontaneously unlike small intestinal perforations.