Thomas Cerabona

Extremely High Body Mass Index is not a Contraindication to Laparoscopic Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is an effective operation for morbidly obese patients who have failed conservative weight loss treatments. It is currently indicated for patients with BMI >40 kg/m2 or >35 with significant co-morbidities. Controversy exists whether there is an upper limit to BMI beyond which this operation should not be performed. Methods: Between April 1999 and February 2001, 82 patients (19 male, 63 female) underwent LRYGBP. Average age was 43.6, and average BMI was 56 kg/m2. These patients were divided into those with BMI <60 and those with BMI ≥60 kg/m2. Results:There were 61 patients with BMI <60 and 21 patients with BMI ≥60. The groups were similar in age, gender, distribution or incidence of co-morbid conditions (diabetes, coronary artery disease, hypertension, sleep apnea, asthma) between the groups. The BMI ≥60 group had a significantly longer length of stay (6.6 days vs 5.3 days, P <0.05), and only 1 patient (BMI 85) developed an anastomotic leak and died. 2 patients in this group (BMI 62 and 73) developed small bowel obstruction requiring lysis of adhesions. 1 patient in the BMI <60 group developed a gastrojejunal stricture requiring balloon dilatation. Conclusion: While patients with a BMI ≥60 are at higher risk for postoperative complications, they are also at higher risk from continued extreme obesity. In our series, 85% of these patients had an uneventful postoperative course and began shedding excess weight. BMI ≥60 should not be a contraindication for LRYGBP.

An Alternative Technique for Creating the Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass: Experience with 28 consecutive patients

Background:This study illustrates our experience in laparoscopic Roux-en-Y gastric bypass (LRYGBP) using a new technique for creating the gastrojejunostomy. Methods: Between April and November 1999, 28 patients underwent LRYGBP. In the first 10 patients the transoral route with endoscopic guidance was utilized for placement of the anvil in the gastric pouch. A new totally intra-peritoneal approach was utilized in the next 18 patients, avoiding the transoral route. Results:There were 23 women and 5 men with an average age of 36 years (range 24-51). The mean BMI was 47, with range 41-64. Of the patients, 82% had one or more associated co-morbid conditions (hypertension, diabetes, sleep apnea, arthritis). Average operative time in the first 10 patients using the trans-oral route with endoscopic guidance was 340 minutes (range 240-390 min). The next 18 patients underwent totally intra-peritoneal anvil placement with a 240-minute average operating time (range 150-310 min). There were no open conversions or mortalities.There were 4 complications, including 2 wound infections, one urinary tract infection, and one intra-abdominal abscess. The two wound infections occurred in the first 10 patients that underwent trans-oral introduction of the anvil. Conclusions: LRYGBP was a safe and feasible operation. We believe that our technique is easily reproducible, avoiding the trans-oral route for introducing the anvil. This technique may also decrease operative time and possibly the incidence of wound infections, although we are still in the learning curve and final conclusions cannot be made.

Transmesenteric-Transfemoral Method of Intrahepatic Portosystemic Shunt Placement with Minilaparotomy

PURPOSE To determine whether the transmesenteric-transfemoral method of intrahepatic portosystemic shunt (IPS) placement is safer and more efficient than the transjugular method. PATIENTS AND METHODS Sixty-six consecutive patients with cirrhosis and bleeding varices underwent 67 IPS procedures. Sixty-one of these procedures were performed using a combination of transfemoral access to the hepatic vein with transmesenteric access to the portal system provided by means of minilaparotomy. Follow-up days were collected periodically by means of clinical evaluation and duplex sonography of the shunt. Angiographic evaluation was performed when necessary. RESULTS No technical failures or periprocedural deaths occurred. The radiologic and surgical portions of the procedure were accomplished within 45 and 55 minutes, respectively. In cases without portal thrombosis, maximum fluoroscopy time was 12 minutes. During follow-up (mean, 16 months), eight shunt revisions including one additional shunt placement were necessary. CONCLUSION Transmesenteric-transfemoral IPS placement requires surgical participation but may offer improved efficiency and safety compared with regular transjugular IPS placement.

Right ventricular systolic function is not depressed in morbid obesity.

Background: The increased pulmonary blood volume associated with the increased total blood volume in morbidly obese patients increases pulmonary artery pressure and pulmonary vascular resistance, resulting in increased right ventricular (RV) afterload. Thus, the morbidly obese may develop RV dysfunction owing to the increased RV afterload. We examined this possibility by assessing RV contractile function in morbidly obese patients, using RV end-systolic pressure-volume relationship and RV systolic time intervals. Methods: Included were 25 morbidly obese patients undergoing gastric bypass surgery under general anesthesia. Pulmonary artery pressure and RV end-systolic volume were measured with a thermodilution pulmonary artery catheter. Pulmonary arterial dicrotic notch pressure was used as an estimate of RV end-systolic pressure. Two data points were used to define RV end-systolic pressure-volume relationship. RV systolic time intervals were determined by simultaneous graphic display of the electrocardiograph, phonocardiograph, and pulmonary artery pressure curve, and were expressed as a pre-ejection period/RV ejection time ratio. Results: The mean slope of right ventricular end-systolic pressure-volume relationship line was 0.54 ± 0.13 and mean pulmonary vascular resistance 274 ± 80 dyne·sec·cm−5·m−2. The mean pre-ejection period/RV ejection time ratio was 0.4 ± 0.11. There was an inverse correlation between the pre-ejection/RV ejection time ratio and the slope of RV end-systolic pressure-volume relationship line (R2=0.658, P<0.0001). Conclusion: Our data indicate that RV function is not depressed in morbid obesity despite increased RV afterload.

Increased pulmonary venous resistance in morbidly obese patients without daytime hypoxia: clinical utility of the pulmonary artery catheter.

Background:The pulmonary artery (PA) diastolic-pulmonary capillary wedge pressure (PAD-PCWP) gradient has been shown to be increased in morbidly obese patients without daytime hypoxia. In sepsis, the increased pulmonary venous resistance (PvR) contributes to increases in PAD-PCWP gradient. In addition, the obesity-related endotoxemia is known to be involved in the pathophysiology of metabolic syndrome in obesity. Therefore, it is possible that the increased PvR contributes to increases in PAD-PCWP gradient in morbid obesity. We examined this possibility. Methods:Included were 25 obese patients without daytime hypoxia undergoing bariatric surgery under general anesthesia. PvR was calculated as the difference between mean PA output pressure and PCWP divided by cardiac index. Mean PA output pressure was computed from the harmonic form of the recorded PA pressure by applying an attenuating factor to its phasic components, for which Fourier analysis was used. Total pulmonary vascular resistance (TPVR) was calculated as the difference between mean PA pressure and PCWP divided by cardiac index. To avoid the effect of PA resistance on TPVR and PvR, the PvR/TPVR ratio was used. Results:There was a good correlation between PvR/TPVR ratio and PAD-PCWP gradient (r2 = 0.785, P < 0.0001). When patients were divided into two groups based on PAD-PCWP gradient, the PvR/TPVR ratio was 0.67 ± 0.06 (mean ± SD) in the group with a PAD-PCWP gradient of at least 6 mmHg and 0.48 ± 0.05 in the other group (P < 0.0001). Conclusions:A strong correlation between PvR/TPVR ratio and PAD-PCWP gradient suggests that the increased PvR contributes to increased PAD-PCWP gradient in obese patients without daytime hypoxia.

OPEN VERSUS CLOSED TREATMENT OF NECROTIZING PANCREATITIS

The records of 30 consecutive patients who underwent operative procedures for infected (25 patients) and sterile (5 patients) necrotizing pancreatitis were reviewed. 17 patients were managed by an open procedure and 13 patients by a closed procedure. Overall mortality was six patients (20%). All the mortalities were among the 25 infected patients and among the 16 patients managed open. Open management was associated with higher Apache II scores at admission (13.5 vs. 8.5) (p < .05). Nonsurvivors had a higher Ranson prognostic criteria score, first CT severity index, and Apache II score versus survivors (16.8 vs. 10) (p < .05). Open management was associated with more operations, more transfusions of blood, and longer length of intensive care unit and hospital stays. All mortalities were secondary to multiple organ failure. There were more local complications in the open group (fistulas and colon necrosis). At the initial operation, infected patients demonstrated predominantly emerging resistant flora. Open management is associated with a higher morbidity and mortality; however, due to the progressive nature of the pathology, repeated explorations are necessary in the more severely ill patients with necrotizing pancreatitis.

Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature.

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmanns pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones.