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Intravenous (i.v.) acetaminophen has the potential to reduce postoperative narcotic analgesic requirement but this has not been reported in bariatric surgery. As lower dosages could reduce undesirable narcotic side effects, we investigated the opioid-sparing effect of concomitant i.v. acetaminophen in bariatric surgery.We performed a retrospective review of our electronic medical records of laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed for severe obesity between 2011 and 2013. We identified 183 patients that received scheduled i.v. acetaminophen in addition to morphine sulfate (MSO4) patient-controlled analgesia (PCA). A cohort of 229 patients from the preceding 2 years who were treated with MSO4 PCA but not acetaminophen was used as a historical control. Patient demographic characteristics and narcotic use data were extracted from electronic medical records. Student's t test or linear regression was used as appropriate (P.05).During the first 24-hour postoperative period after LRYGB, narcotic analgesic demand (total PCA demand including nondelivery of narcotic due to lock-out) was reduced by 25% with the concomitant use of i.v. acetaminophen (40.5 versus 30.9 average pushes; P.05). During the same period, narcotic analgesic dosage requirement was cut down by 20% in the study group (average of 29.9 versus 24.1 mg of MSO4; P.05). Linear regression analysis confirmed that these changes were independent of age, gender, and body mass index distribution, or type 2 diabetes mellitus.Scheduled i.v. acetaminophen reduces the demand for and the requirement of narcotic analgesia after LRYGB. We provide new evidence in support of the routine use of multimodal analgesia that includes scheduled i.v. acetaminophen in the initial 24-hour period after bariatric surgery.

Background Bariatric surgery provides for a reliable and sustainable solution to the obesity epidemic. The gold standard bariatric surgical procedure is the Roux-en-Y gastric bypass (RYGB). Assessment of this population preoperatively and work-up of postoperative complications often includes radiographic evaluation. Repeated exposure to radiation is not without complication. Objective Assess the association between the RYGB and exposure to ionizing radiation. Setting Academic medical center. Methods Patients were identified by their ICD-9 code as having had a RYGB at the Massachusetts General Hospital (MGH) from 2002 to 2012. The number of abdominal and pelvis (A/P) computed tomography (CT) scans performed was determined and converted into an effective dose (ED) and expressed as milliSeiverts (mSv) to illustrate the biologic effects of radiation. Results From 2002 to 2012, 1789 primary laparoscopic RYGBs were completed. Fifty-five revisional operations were completed on 51 patients. Of these, 38 had both their index and second operation at the MGH. A total of 1065 A/P CTs were completed in the laparoscopic RYGB population (mean = .6), and 106 A/P CTs were done in the revisional surgery cohort (mean = 2.8). The mean ED of radiation was 56.1 mSv and 19.5 mSv for the index and revisional populations, respectively. Conclusions This study demonstrated the significant cumulative radiation exposure attributable to A/P CTs. This exposes the patient to a potential increased risk of malignancy as well as imposing a financial burden on the healthcare system. The findings of this study raise the awareness of an increased risk of radiation exposure for this population and the necessity of creation of a dedicated algorithm for the mindful utilization of CT imaging.

Objectives The reference standard technique for the reconstruction of the extrahepatic biliary tree is Roux-en-Y hepaticojejunostomy. This procedure is not without complications and may not be feasible in some patients. This project sought to evaluate a novel approach for repairing common bile duct injuries with a biosynthetic graft. This allows for the reconstruction of the anatomy without necessitating an intestinal bypass. Methods Study subjects were 11 mongrel hounds. Utilizing an open approach, the common bile duct was transected in each animal. A 1-cm graft of a synthetic bioabsorbable prosthesis was interposed over a 5-Fr pancreatic stent and sewn in place as an interposition tube graft with absorbable sutures. Intraoperative cholangiograms and monthly liver function tests were completed. Animals were killed at 6, 7, 8, 10 and 12 months. Results The first five animals were killed early in the process of protocol development. One animal developed obstructive symptoms and was killed on postoperative day 14. The next five animals were longterm survivors without evidence of clinically significant graft stenosis. Mean alkaline phosphatase and total bilirubin were normal, at 140 U/l and 0.2 mg/dl, respectively. Histology showed the complete replacement of the graft with native tissue at 6 months. Conclusions Biliary reconstruction using a synthetic bioabsorbable prosthetic as an interposition tube graft is feasible based on initial results. Biliary reconstruction using a synthetic bioabsorbable prosthetic is possible

Background Diagnostic transgastric endoscopic peritoneoscopy has been used to evaluate the abdomen. We present our experience with transgastric endoscopic peritoneoscopy (TEP) to access the peritoneum, direct trocar placement, and perform adhesiolysis without laparoscopic visualization in patients undergoing laparoscopic Roux-en-Y gastric bypass. Methods Forty patients participated. There are 2 arms to the study. The initial 20 patients underwent pre-insufflation of the abdomen prior to TEP. The second 20 had no pre-insufflation. Ten patients in each arm had no surgical history. The other 10 had previous intra-abdominal procedures. TEP was performed through a gastrotomy created without laparoscopic visualization. Adhesions were visualized and taken down endoscopically prior to trocar placement. Diagnostic findings, operative times, and clinical course were recorded. Results Average TEP time was 19 min. Three patients had limited visualization due to intra-abdominal adhesions (2) and omental fat (1). Three of the 20 without and 17 of 20 with a history of intra-abdominal surgery had adhesions visualized endoscopically. Endoscopic adhesiolysis was performed in 1 and 4 patients in these groups respectively. Six occult umbilical hernias, 1 inguinal hernia, and 1 hiatal hernia were noted on endoscopic exploration. There were no complications related to intubation of the stomach, accessing the peritoneum, or endoscopic exploration. Conclusion TEP is a safe and accurate means to access the peritoneum, visualize the abdominal wall, perform adhesiolysis, and direct trocar placement without laparoscopic guidance. Safe and reliable gastric closure remains the sole limitation to its clinical use outside of a protocol necessitating a gastrotomy.

Background Diagnostic transgastric endoscopic peritoneoscopy is a safe model for exploration of the peritoneum. Endoscopic insufflation of the peritoneal cavity has not been validated in humans. We report here our experience with pneumoperitoneum established endoscopically with a laparoscopic insufflator. Design Pneumoperitoneum was established with a laparoscopic insufflator through the biopsy channel of the gastroscope. Intra-abdominal pressure was measured with a transfascial Veress needle and compared with endoscopic values. The gastrotomy was used in the creation of the gastric pouch. Patients Twenty patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Ten had undergone no previous surgery, whereas the other 10 patients had a history of abdominal procedures. Interventions Diagnostic transgastric endoscopic peritoneoscopy was performed through a gastrotomy created endoscopically without laparoscopic visualization. Main Outcome Measurements Diagnostic findings, operating times, and clinical course were recorded. Results The average time for transgastric access was 9.6 minutes. This did not vary in patients with previous surgery ( P = .3). Endoscopic insufflation was successful in all patients. The mean endoscopic and laparoscopic pressures were 9.80 and 9.75 mm Hg, respectively ( P = .9). In no patients were there limitations to visualization of the abdomen. Adhesions were noted in 80% and 10% of patients with and without a history of surgery, respectively ( P = .005). There were no complications related to transgastric passage of the endoscope or exploration of the peritoneal cavity. Conclusions Although limited by the small sample size in this study, we believe that transgastric access may be considered as an alternative approach to peritoneal insufflation and provides a safe alternative for exploration of the abdomen. Endoscopic insufflation through the biopsy channel by using a laparoscopic insufflator seems to be an effective and safe method for establishing pneumoperitoneum.

m p n c e l Primary chyloperitoneum is uncommon outside of the ediatric population. Secondary chylous ascites is most ofen due to neoplastic disease, but it can be caused by xtensive dissection during abdominal operations, trauma, r inflammatory states [1]. Prolonged extravasation of chyle into the peritoneal cavty has numerous potential complications. For example, atients are susceptible to malnutrition. Accumulation of hyle produces abdominal distension and pain. Additionlly, immunosuppression secondary to the loss of lymphoytes can occur. Also, the protracted loss of protein-rich ymph can cause protein loss, further increasing the suscepibility to infectious complications [1]. No consensus has been reached regarding the therapeutic pproach for this condition. Many have advocated initial onoperative treatment with dietary modification alone. Duue et al. [2] reported chylous fistula closure in 80% of atients treated using this regimen. Operative therapy has een reserved for those in whom medical management has ailed. We present a report of 2 patients who developed hylous ascites after laparoscopic adjustable gastric band LAGB) placement, with disease resolution after operative anagement.