Search

Introduction: Obesity is a major risk factor for idiopathic intracranial hypertension (IIH). Effective therapeutics for preventing disease progression and alleviating symptoms are limited. This study aims to examine the effects of bariatric surgery on clinical outcomes of IIH., Methods: We retrospectively collected data from the medical record of 97 patients with obesity and an existing diagnosis of IIH who underwent primary bariatric surgery at the Cleveland Clinic health system in the USA between 2005 and 2023. Pre- and postoperative data on presence of symptoms and clinical markers of IIH (headaches, visual field defects, papilledema, visual symptoms), intracranial pressure, and usage of IIH medications were compared., Results: A total of 97 patients (98% female, median age 46.7 years, median BMI 48.3 kg/m 2 ) with IIH who underwent bariatric surgery including Roux-en-Y gastric bypass (n = 66, 68%), sleeve gastrectomy (n = 27, 27.8%), and gastric banding (n = 4, 4.1%) were analyzed. In a median follow-up time of 3.0 years, the median total weight loss was 24% (interquartile range, 13-33%). There was a significant improvement in headache, papilledema, visual field deficits, and visual symptoms after bariatric surgery. The mean lumbar opening pressure before and after bariatric surgery was 34.8 ± 8.2 cm CSF and 24.2 ± 7.6 cm CSF, respectively, with a mean reduction of 10.7 cm CSF (95% confidence interval, 4.7 to 16.6), p = 0.003. The dosage of acetazolamide and topiramate, as well as the number of medications taken for IIH, decreased significantly after bariatric surgery (p < 0.001)., Conclusion: For patients who have obesity, bariatric surgery is a viable treatment modality for alleviation or improvement of symptoms of IIH., (© 2024. The Author(s).)

Background: Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy., Methods: Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal., Results: During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03-6.94, p = 0.044)., Conclusion: Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy., (© 2024. The Author(s).)

Purpose: Excessive post-operative opioid prescribing has led to efforts to match prescriptions with patient need after surgery. We investigated opioid prescribing practices, rate of patient-requested opioid refills, and associated factors after laparoscopic inguinal hernia repair (LIHR)., Methods: LIHRs at a single institution from 3/2019 to 3/2021 were queried from the Abdominal Core Health Quality Collaborative for demographics, perioperative details, and patient-reported opioid usage. Opioid prescriptions at discharge and opioid refills were extracted from the medical record. Univariate and multivariable regression were used to identify factors associated with opioid refills within 30-days of surgery., Results: Four hundred and ninety LIHR patients were analyzed. The median number of opioid tablets prescribed was 12 [interquartile range (IQR) 10-15], and 4% requested a refill. On univariate analysis, patients who requested refills were younger [55 years (IQR 37-61) vs. 62 years (IQR 36.8-61), p = 0.012], more likely to have undergone transabdominal preperitoneal repair (75% vs. 26.4%, p < 0.001), have a scrotal component (30% vs. 11%, p = 0.022), and have permanent tacks used (80% vs. 49.4%, p = 0.014). There was a 12% increase in the odds of opioid refill for every 1 tablet of oxycodone prescribed at discharge (95% CI for OR 1.04-1.21, p = 0.003) after controlling for age and surgery type. Patient-reported opioid use was available for 289 (59%) patients. Post-operatively, 67% of patients used ≤ 4 opioid tablets, and 87% used no more than 10 opioid tablets., Conclusion: Most patients use fewer opioid tablets than prescribed. Requests for opioid refills are rare following LIHR (4%) and associated with higher opioid prescribing., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC., Methods: In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF., Results: The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed., Conclusions: Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Background: Feeding jejunostomy is an alternative route of enteral nutrition in patients undergoing major gastrointestinal operations when a feeding gastrostomy is not suitable., Methods: A single institution review of patients who underwent open or laparoscopic jejunostomy tube (JT) placement between 2009 and 2019 was performed. Data collected included demographics, preoperative serum albumin, surgery indication, concomitancy of procedure, size of JT tube and time to its removal. JT complications were analyzed in the early postoperative period (< 30 days) and in a long-term follow-up (> 30 days). The Chi-square test was used to compare rates of complications according to tube size., Results: Seventy-three patients underwent JT placement, and gastroesophageal cancer (n = 48, 65.7%) was the most common indication. The JT was most frequently placed concomitantly (n = 56, 76.7%) to the primary operation and through a laparoscopic approach (n = 66, 90.4%). A total of 14 patients (19.1%) had early complications and 15 had late complications (20.5%). The reasons for early complications were clogged JT (n = 8, 10.9%), JT dislodgement (n = 3, 4.1%), leakage (n = 2, 2.7%), small bowel obstruction adjacent to the site of the jejunostomy tube (n = 2, 2.7%), JT site infection (n = 1, 1.3%), and intraperitoneal JT displacement (n = 1, 1.3%). The reasons for late complications were clogged JT (n = 6, 8.2%), JT dislodgement (n = 6, 8.2%), JT site infection (n = 3, 4.1%), and JT leakage (n = 1, 1.3%). There was no procedure-related mortality in this series. However, 12 patients (16.4%) died due to their baseline disease. The mean time to tube removal was 83.4 ± 93.6 days. The most frequently used JT size was 14 French (n = 39, 53.4%) but in nine patients the tube size was not reported. No statistical significance (p = 0.75) was found when comparing the two most commonly used sizes to rates of complications., Conclusion: The rate of JT complications in our study is comparable to other published reports in literature. As an alternative route for nutritional status optimization, the procedure appears to be safe despite the number of complications.

Background: Arterial hypertension (HTN) is one of the most important risk factors for the development and progression of chronic kidney disease (CKD). Rapid weight loss after bariatric interventions has a positive impact on blood pressure levels of hypertensive patients. The aim of our study is to assess the prevalence of HTN in patients with CKD after bariatric surgery (BS)., Methods: We retrospectively reviewed severely obese patients who underwent BS from 2010 to 2017. We used guidelines of the American College of Cardiology to define HTN. Only patients meeting ACC criteria and the calculation of estimated glomerular filtration rate (eGFR) using CKD epidemiology collaboration study equation preoperatively and at 12-month follow-up were included in the analysis., Results: From a total of 2900 patients, 29.13% (845) met the required criteria and had variables for the calculation of eGFR recorded preoperatively. 36.92% (312) had preoperative HTN and s classified as CKD stage ≥ 2. We observed a predominantly female population 63.83% (203) with mean age of 54.10 ± 11.58. Patients preoperatively classified in CKD 2, 3a, and 3b exhibited the greatest prevalence reduction of HTN at 12-month follow-up (68.59%, n = 214 vs. 36.59%, n = 114; 16.67%, n = 52 vs. 6.41%, n = 20; 7.69%, n = 24 vs. 1.28%, n = 4; p < 0.0001). A marked improvement in CKD was also observed along with improvement in HTN. The greatest benefit corresponded to patients classified preoperatively in CKD 2, 3a and 3b. A total of n = 70 (62.5%) patients with HTN were classified as CKD 2 preoperatively compared to n = 55 (49.11%) at 12-month follow-up (p = 0.0436). Similarly, n = 22 (19.64%) patients with HTN were classified preoperatively as CKD 3a compared to n = 7 (6.25%) and n = 12 (10.71%) patients as CKD 3b compared to n = 4 (3.57%) during the same time period (p = 0.0028, p = 0.0379, respectively)., Conclusions: Rapid weight loss after BS significantly reduces prevalence of HTN in all stages of CKD at 12-month follow-up. Additionally, there was a positive impact on classification of CKD at 12-month follow-up.

Introduction: Atherosclerotic cardiovascular disease (ASCVD) and Framingham risk scores (FRS) are used to calculate 10-year risk of coronary death, nonfatal myocardial infarction, or fatal/nonfatal stroke. Our goal is to evaluate the association between preoperative cardiovascular risk and weight loss., Methods: We retrospectively reviewed bariatric surgeries from 2010 to 2016. Patients who met criteria for calculating 10-year ASCVD score and FRS were included. Data collected included baseline demographics, perioperative parameters, and postoperative outcomes at 12 months. Simple linear regression and multiple linear regression models were applied to test influence of individual or multiple factors of interest on 12-month weight loss outcomes., Results: Of 1330 bariatric patients studied, 360 patients met criteria for ASCVD and FRS calculation. Sleeve gastrectomy (LSG) was the most prevalent surgery 63.05%, followed by Roux-en-Y gastric bypass (LRYGB) 20.55%, revision procedures 11.9%, and adjustable gastric banding (LAGB) 4.4%. Initial BMI was 42.71 ± 7.85 kg/m 2 for females and 42.72k ± 7.42 kg/m 2 for males, with a 12-month percentage of estimated BMI loss (%EBMIL) of 66.51% in females and 60.29% in males. Preoperative 10-year ASCVD score was higher in males than females with a 34.73% relative risk reduction (RRR) in males and 35.3% RRR in females at 12-month follow-up. Regarding FRS, preoperative risk was 33.13 ± 21.1% in males and 15.71 ± 14.52% in females, with an RRR of 25.8% in males and 32.2% in females. Univariate analysis of preoperative FRS and %EBMIL showed that for every percentage unit increase in the patient's preoperative FRS, %EBMIL decreases 0.31 percentile unit (P < 0.001). Furthermore, preoperative ASCVD score is also significantly associated with %EMBIL-for every percentage unit increase in preoperative ASCVD score, %EBMIL decreases 0.42 percentile credits., Conclusion: Study results suggest ASCVD and FRS are equally reduced after bariatric surgery, especially after LSG and LRYGB. Moreover, preoperative FRS and ASCVD risk score showed an inversely proportional relationship with %EBMIL loss at 12 months.

Background: There is vast evidence that supports the importance of obesity in the pathogenesis and progression of cardiovascular disease. Rapid weight loss induced by laparoscopic Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (LAGB) has proven beneficial. The aim of this study is to evaluate laparoscopic sleeve gastrectomy (LSG) as an alternative treatment modality and its impact on the Framingham-BMI 10-year risk score., Methods: We retrospectively reviewed all patients that underwent bariatric surgery at our institution between 2010 and 2014. Patients who met the criteria for calculating the Framingham BMI 10-year risk score were included. Data collected included baseline demographics, perioperative parameters such as tobacco use, diagnosis of diabetes, treatment for hypertension, BMI and postoperative outcomes at 3 and 12 months., Results: From our 1129 bariatric patients, 358 (31.7%) met criteria for the Framingham BMI 10-year risk score calculation. LSG was the most prevalent surgery 61.45% (N = 220) followed by LRYGB 22.06% (N = 79). Females composed 69% (N = 248) of our population. The average age for females was 52.3 ± 10.8 years and for males 54.07 ± 11.2 years. The initial Framingham 10-year score risk was significantly higher in males compared with females (36.16% ± 22.3 vs. 16.97% ± 15.6 (p < 0.001)). After 12-month follow-up, the absolute risk reduction in males was 11.58% (p < 0.001) and 6.17% in females (p < 0.001). The preoperative heart age was high in females and males (69.23 ± 15.72 years and 73.55 ± 13.55 years, respectively (p = 0.012)), and after 12 months it was reduced 7.19 years in females (p < 0.001) and 7.04 years in males (p < 0.001). The percentage of estimated BMI loss at 1 year was 64.43% in females and 60.69% in males., Conclusion: Sleeve gastrectomy has demonstrated to be an effective method of treatment for obesity. Our results suggest that rapid weight loss after LSG has a positive impact in the reduction of the 10-year cardiovascular disease risk. Further prospective studies may be needed to better assess these findings.

Background: Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot's triangle. This study evaluates the identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents., Methods: Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot's triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy., Results: Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (p = 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (p = 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (p = 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (p = 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (p = 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (p = 0.0001)., Conclusions: IOIFC increases the visualization of Calot's triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.

Background: Bariatric surgery has proven to be the most effective treatment for morbid obesity in all age groups and is considered superior to medical treatment. The aim of our study was to report the outcomes of bariatric surgery in patients over 65 years of age at our institution., Methods: A retrospective review of a prospectively collected database was conducted of all patients > 65 years who underwent a bariatric procedure between 2005 and 2015 at our institution. We compared this group to a control group of patients < 65 years of age who were operated on during the last 5 years, from 2011 to 2015. Data analyzed included age, preoperative BMI, postoperative complications, and comorbidities., Results: Of 1613 patients studied, 1220 patients were under 65 years of age, and in Group B, 393 were >65 years of age at time of surgery. There was a significant difference in proportion of male patients among groups; 42 % in Group B were male compared to 30 % in Group A (p < 0.001). Caucasians represented the majority in both groups. Both groups had comparable preoperative BMI 42.27 kg/m 2 for the younger Group A population versus 41.64 kg/m 2 for Group B (p = 0.074). Group B had more comorbidities than Group A: hypertension (p < 0.001), sleep apnea (p < 0.001), and hypercholesterolemia (p < 0.001). No difference was found between groups in history of depression (p = 0.409) or type II diabetes (p = 0.961). Distribution of procedures was significantly different between groups, with more LSG in Group A (p < 0.001). Elderly patients had longer length of stay (LOS) by one day on average (LOS = 3 days, p < 0.001), but a lower readmission rate (10 % vs. 7 %) (p = 0.023). Complication rates were comparable in both groups, except for incidence of de novo GERD, which was higher in Group B (5 % vs. 8 %) (p = 0.005)., Conclusions: Elderly patients are usually sicker in terms of comorbidities than the younger population. However, age does not seem to represent a risk of surgical complications after bariatric surgery.

Background: LSG is widely accepted as a definitive treatment for obesity. Due to lack of large series with long-term follow-up, disagreement remains regarding its safety and efficacy. We present a series of 1020 consecutive LSGs performed with long-term follow-up., Methods: A retrospective review of a prospectively collected database was conducted on patients who underwent LSG from January 2005 to February 2014. Data included weight, height, BMI, ideal body weight, comorbid conditions, intraoperative complications, mean length of hospital stay (LOS), early (<30 days) readmission, early and late (>30 days) postoperative complications, and percentage of excess weight loss (%EWL)., Results: Of the 1020 patients, 66.6 % (n = 679) were female, with a mean age of 38.4 ± 16.5 years. Mean BMI at the time of first visit was 43.4 ± 5.8 kg/m(2). The most common comorbid conditions identified were diabetes mellitus (89.4 %), sleep apnea (86.4 %), hypertension (80.3 %), and hyperlipidemia (70 %). Over the entire follow-up period, 57 % of diabetic patients experienced significant improvement or remission. There was no mortality in this series. Early postoperative complications within 30 days of surgery included leak in 0.1 % (n = 1), stricture in 0.1 % (n = 1), emesis in 23 % (n = 234), dehydration in 19 % (n = 194), prolonged ileus in 18 % (183), and self-limited bleeding in 3 % (n = 30). Mean LOS was of 3.4 ± 2.1 days, with a 3.8 % overall rate of early readmissions. Long-term morbidity was found in 3.9 % of patients (n = 40) and included stricture in 0.49 % (n = 5) and GERD in 6 % (n = 61). The overall 30-day mortality rate was 0 %. Mean %EWL at 3 months to 1, 3, 5, and 8 years was 72 ± 16.8, 86 ± 22.3, 63 ± 19, 61 ± 11, and 52 ± 9.2, respectively., Conclusions: This study confirms that LSG is safe and has very low rates of early and long-term complications when compared to other well-established procedures. Additionally, LSG that appears results in significant improvement of obesity-related comorbid conditions.

Background: Measurements of optic nerve sheath diameter (ONSD) with noninvasive ocular ultrasonography have been shown to be accurate in determining increased intracranial pressure. Obesity is associated with chronic increases in intraabdominal pressure that could consequently result in intracranial hypertension. By utilizing ONSD ultrasonographic measurements, we compare the difference that may exist between obese and non-obese patients., Study Design: We prospectively collected data from patients who underwent laparoscopic procedures in the supine position between July 2013 and March 2014. Ophthalmic pathology was not present in any patient. Ultrasonographic measurement of the ONSD was obtained sagittally with a 12-MHz transducer 3 mm from its origin. The measurements were taken at 0, 15, and 30 min, and at the end of surgery., Results: There were 62 subjects, 28 females (45.2 %) and 34 males (54.8 %), with a mean age of 44.22 ± 10.44 years (range 23-66). Forty-eight percent of patients were non-obese, and 52 % of patients were obese. The mean body mass index was 30.70 ± 7.61 kg/m(2) (range 20.0-59.5). The mean ONSD of non-obese and obese patients was 4.7 and 5.5 mm at baseline (p = 0.01), 5.4 and 6.2 mm at 15 min (p = 0.01), 5.8 and 6.6 mm at 30 min (p = 0.01), and 5.1 and 5.7 mm after deflation of pneumoperitoneum (p = 0.03), respectively., Conclusions: Utilizing a noninvasive method to measure the ONSD, a chronic increase in intracranial pressure in obese patients was demonstrated. The increase in the ONSD during laparoscopic procedures reflects a temporary increase in the intracranial pressure from baseline.

Background: Incisional hernias remain a significant complication of abdominal surgeries. Primary closure of the hernia defect has been suggested to improve long-term abdominal wall function. However, this can be technically challenging and time consuming. This study describes laparoscopic use of non-absorbable barbed sutures in primary closure of hernia defects in addition to intraperitoneal mesh., Methods: Patients who underwent laparoscopic primary ventral hernia repair with mesh were prospectively reviewed. Two groups were defined: Operations performed with barbed sutures for primary closure in addition to mesh and operations with only mesh without defect repair. The surgical technique involved running the hernia defect with a 2-polypropylene non-absorbable unidirectional barbed suture and subsequently fixing the mesh intraperitoneally with tacks. In both groups, a single transfascial centering suture was also utilized., Results: Twenty-eight cases with barbed suture and mesh reinforcement and 29 cases with mesh-only were identified. The average dimensions of the ventral hernia defects were 57.8 (6-187) and 44.6 cm(2) (9-156) in the barbed suture with mesh and mesh-only group, respectively, p = 0.23. Median operating time was 78 min (range 35-187 min) in the barbed suture with mesh group versus 62 min (34-155 min) in the mesh-only group, p = 0.44. The median suturing time of closing the ventral hernia defect was 16 min (11-24 min). There were no differences in the pain scores. Mean follow-up for both groups was 8.2 ± 3.6 months (1-17 months) with one hernia recurrence in the mesh-only group, p = 0.41., Conclusions: The barbed suture closure system could be used for rapid and effective primary defect closure in laparoscopic ventral hernia repair in addition to intraperitoneal mesh placement. No significant difference in operating time was detected when compared to the mesh-only approach. Further evidence to support these findings and longer follow-up periods is warranted to evaluate short- and long-term complications.

Background: Acute elevations of intraabdominal pressure (IAP) are seen in many clinical scenarios with a consequent elevation in intracranial pressure (ICP). With the optic nerve sheath (ONS) being a part of the dura mater and the optic nerve surrounded by cerebral spinal fluid, a change in pressure within the subarachnoid space would be detected by ultrasonography, and invasive methods could be avoided. The study objective was to evaluate ultrasonographic modifications observed on the optic nerve sheath diameter during acute elevations of IAP in patients undergoing laparoscopic procedures., Study Design: We prospectively collected data from patients who underwent laparoscopic procedures between July and August 2013. The optic nerve sheath diameter was measured sagittally with a 12-MHz transducer. The measurements were obtained at baseline, 15 and 30 min, and at the end of surgery., Results: There were 16 females (36.4%) and 28 males (63.6%), with a mean age of 44.22 ± 10.44 years (range 23-66) and body mass index of 29.45 ± 6.53 kg/m(2) (range 21-39). The mean optic nerve sheath diameter was 4.8 ± 1.0 mm at baseline, 5.5 ± 1.1 mm at 15 min, 5.9 ± 1.0 mm at 30 min, and 5.1 ± 1.2 mm after deflation of pneumoperitoneum. The diameter increased significantly at 15 min by a median of 0.6 mm (interquartile range 0.3, 0.8; p < 0.0001) and at 30 min by a median of 1.0 mm (interquartile range 0.7, 1.4; p < 0.0001), returning close to baseline after surgery., Conclusion: The acute elevation in IAP during laparoscopy significantly increased the optic nerve sheath diameter. The changes in the ONSD reflect a temporary and reversible increase in the ICP due to the acute elevation of IAP.

Background: Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative incisionless fluorescent cholangiography were evaluated in a consecutive series of cases., Methods: A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used., Results: IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient, p = 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes, p < 0.0001). The cystic duct was identified by IOFC in 44 out of 45 patients (97.77 %)., Conclusion: IOIFC appears to be a feasible, low-cost, expeditious, useful, and effective imaging modality when performing LC. It is safe, easy to perform and interpret, and does not require a learning curve or X-ray. It can be used for real time surgery to delineate the extrahepatic biliary structures.

Background: Identification of adrenal glands from the surrounding structures during laparoscopic surgery can be challenging especially in obese individuals. This can increase the chances for hemorrhage and conversion to open surgery. We present the first report of fluorescent infrared visualization of the adrenal glands in a large animal model., Methods: Five adult Yorkshire pigs were utilized for the study, in compliance with the animal study regulations. After an intravenous bolus administration of 3 mL of indocyanine green (ICG), visualization was performed with a xenon/infrared light source and a laparoscope with a charge-coupled filter device. Activation of the device was done with a foot pedal. Images were analyzed using histogram software and the difference of enhancement was statistically analyzed using unpaired two-tailed t test., Results: The right adrenal glands were visualized in all five animals immediately after administering ICG. Fluorescence facilitated demarcation of adrenal gland tissue from surrounding adipose tissue. Peritoneum and fat was visualized in black color. Adrenal enhancement lasted for 4 h in all cases. The mean value for adrenal fluorescence using histogram count was 71.75 pixels, and for adrenal xenon was 168.87 pixels (p = 0.0002; 95 % CI -130.93 to -0.63). The mean value for fat fluorescence using histogram count was 5.54 pixels and fat xenon was 187.15 pixels (p = 0.0001; 95 % CI -199.39 to -163.82). Although there was no significant difference between adrenal and fat enhancement with xenon light (p = 0.24; 95 % CI -15.53 to 52.09), the difference became significant between adrenal and fat fluorescence (p = 0.0001; 95 % CI 48.51-83.9)., Conclusion: Fluorescence imaging appears to be a feasible and easy method to differentiate adrenal glands from the surrounding tissue in a large animal model. Further studies are necessary to investigate the real application of this method during laparoscopic adrenalectomy in humans.

Background: Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC., Materials and Methods: Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method., Results: A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m(2). Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100%) and IOC in 40 of 43 cases (93.02%). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful., Conclusion: In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.

Background: Cholelithiasis is a common complication after bariatric surgery. Pure restrictive procedures such as sleeve gastrectomy and gastric banding theoretically should result in less gallstone formation because the food continues to follow the normal gastrointestinal transit, maintaining the enteric-endocrine reflex intact. To the authors' knowledge, the literature has no studies that analyze the incidence of gallstone formation after sleeve gastrectomy. This study aimed to compare the rates of symptomatic gallstones between laparoscopic Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG)., Methods: A retrospective chart review of patients who underwent laparoscopic RYGBP and SG between 2004 and 2006 was performed. The patients with previous cholecystectomy, known gallstones with or without concomitant cholecystectomy, and previous weight-reduction operations were excluded from the analysis. The outcome measures were the numbers of patients who had experienced symptomatic and complicated gallstones. Using Cox regression analysis, comparisons was made between the patients with laparoscopic RYGBP (group A) and those with laparoscopic SG (group B)., Results: Groups A excluded 174 (26%) of 670 patients, and group B excluded 27 (34.2%) of 79 patients. The patients in group A had a significantly higher preoperative body mass index (BMI) than those in group B. Additionally, more group A than group B patients had a BMI exceeding 45 and more than a 25% loss of original weight. No significant difference in the development of symptomatic (8.7% vs. 3.8%; p = 0.296) or complicated (1.8% vs. 1.9%; p = 0.956) gallstones was noted between the two groups, Conclusions: There was no significant difference in symptomatic or complicated gallstone disease between the patients treated with laparoscopic SG and those treated with laparoscopic RYGBP. Routine prophylactic cholecystectomy should not be recommended for weight reduction during laparoscopic SG.

Background: Gastrogastric fistula (GGF) is a rare complication after divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo nondivided or partially divided RYGBP. We have previously reported a GGF rate of 1.5% after divided RYGBP. Remnant gastrectomy has been advocated by our group as a treatment option for this complication. We report our initial experience using the laparoscopic approach., Methods: After IRB approval and following HIPAA guidelines, we conducted a retrospective review of prospectively collected database of 1,796 patients who underwent RYGB from 2001 and to 2008 at the Bariatric and Metabolic Institute. Data included mean time to laparoscopic remnant gastrectomy (LRG), mean length of hospital stay, follow-up period after laparoscopic remnant gastrectomy, rate of conversion, type of procedure performed, and early and late postoperative complications., Results: Twenty-one (1.1%) patients have been diagnosed with GGF; 11 more patients were admitted with GGF after undergoing initial RYGB at another institution. All patients (n = 32) were initially treated with sucralfate and proton pump inhibitors, and 22 of 32 patients eventually underwent LRG: 1 underwent fistulectomy, 1 underwent conversion of vertical banded gastroplasty to RYGB, and the remaining 8 patients have undergone only medical treatment. The mean time to LRG was 9 months from the time of diagnosis of GGF. Two of the 22 patients had conversion to an open approach: one because of a loss of poor visual surgical field resulting from excessive intraluminal air from intraoperative endoscopy and the other as a result of the inability to understand the anatomy laparoscopically. Three of the 22 patients (13%) underwent LRG and redo gastrojejunostomy because of a stenosed gastrojejunostomy. The mean hospital stay after LRG was 4.7 (range, 3-8) days. Early postoperative complications included intra-abdominal bleeding, pneumonia, wound infections, and fever of unknown origin. Late complications included intra-abdominal abscess, wound infections, fever, and food impactation. The follow-up period after LRG was an average of 4 (range, 1-11) months. During the follow-up period, there was no evidence of marginal ulceration, bleeding, abdominal pain, or recurrence of the GGF in any patient., Conclusions: Laparoscopic remnant gastrectomy seems to be a safe and effective treatment option for patients with GGF after RYGBP.

Background: Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery., Method: Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m(2), diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation., Results: 670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12-42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2-37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549-12.498, p = 0.005]., Conclusions: Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified.

Introduction: Many studies have reported on the effects of pneumoperitoneum in a rat model, using a wide range of intra-abdominal pressures. The correlation between pneumoperitoneal pressures in rodents to pressures in humans has not been established. This study evaluates changes in various physiological parameters in different pneumoperitoneum pressures in the rat model with a comparison to known data in humans., Materials and Methods: Three groups of eight Wistar rats each were anesthetized, tracheostomized, and mechanically ventilated with fixed tidal volume and respiratory rate. After a stabilization phase, CO(2) pneumoperitoneum was established to 12, 8, and 5 mmHg in the different groups. Changes in blood pressure, heart rate, peak ventilatory pressure, and end-tidal CO(2) (ETCO(2)) were recorded throughout the experiment., Results: There were no significant changes in blood pressure and heart rate in all groups. No increase in ETCO(2) was demonstrated following induction of pneumoperitoneum in the 12 and 8 mmHg groups. A statistical significant increase in ETCO(2) occurred only in the 5 mmHg group (39.4 to 41.3 mmHg, p = 0.023). Ventilatory pressures increased after induction of pneumoperitoneum in all groups. The increase reached a maximal level in the 8 and 12 mmHg groups (from 3 to 12 mmHg) and was lower in the 5 mmHg group (from 3 to 7 mmHg), Conclusions: The neglected increase in ETCO(2) in pressures > or =8 mmHg, in the rat correlates to high pressures in humans (above 14-20 mmHg) when CO(2) diffusion through the peritoneum declines due to pressure occlusion of peritoneal capillaries. The maximal ventilatory pressures generated in the rat in intra-abdominal pressures > or =8 mmHg correlate to pressures, which are higher than the standard working pressures in humans. Thus, pneumoperitoneal pressures >8 mmHg in the rat do not simulate routine working pressures employed in humans. A pressure of 5 mmHg is optimal in a rat model to simulate laparoscopy in humans.

Background: Morbid obesity is associated with a high prevalence of cholecystopathy, and there is an increased risk of cholelithiasis during rapid weight loss following gastric bypass. In the era of open gastric bypass prophylactic cholecystectomy was advocated. However, routine cholecystectomy at laparoscopic gastric bypass is controversial., Methods: We performed a retrospective review of a prospectively maintained database of morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from February 2000 to August 2006. All had routine preoperative biliary ultrasonography. Concomitant cholecystectomy at LRYGB was planned in patients with proven cholelithiasis and/or gallbladder polyp > or = 1 cm diameter., Results: 1711 LRYGBs were performed. Forty-two patients (2.5%) had a previous cholecystectomy and were excluded from further analysis. Two hundred and five patients (12%) had gallbladder pathology: cholelithiasis in 190 (93%), sludge in 14 (6.8%), and a 2 cm polyp in 1 (0.5%). One hundred and twenty-three patients with cholelithiasis (65%) had a concomitant cholecystectomy at LRYGB, while 68 (35.7%) did not. Of these, 123 (99%) were completed laparoscopically. Concomitant cholecystectomy added a mean operative time of 18 min (range 15-23 min). One patient developed an accessory biliary radicle leak requiring diagnostic laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP). Of the 68 patients with cholelithiasis who did not undergo cholecystectomy 12 (17.6%) required subsequent cholecystectomy. A further 4 patients with preoperative gallbladder sludge required cholecystectomy. All procedures were completed laparoscopically. One patient required laparoscopic choledochotomy and common bile duct exploration (CBDE) with stone retrieval. Eighty-eight patients (6%) with absence of preoperative gallbladder pathology developed symptomatic cholelithiasis after LRYGB; 69 (78.4%) underwent laparoscopic cholecystectomy; 3 presented with gallstone pancreatitis and 2 with obstructive jaundice, requiring laparoscopic transcystic CBDE in 4 and LTG-ERCP in one., Conclusion: In our experience, concomitant cholecystectomy at LRYGB for ultrasonography-confirmed gallbladder pathology is feasible and safe. It reduces the potential for future gallbladder-related morbidity, and the need for further surgery.

Objective: Stricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation., Methods: This is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure., Results: Sixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19-68 years); mean preoperative BMI was 45 kg/m(2) (range: 42-61 kg/m(2)). Mean time from surgery to symptoms onset was 2 months (range: 1-6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation., Conclusion: This is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.

Background: Single-stage laparoscopic sleeve gastrectomy (LSG) may represent an additional surgical option for morbid obesity., Methods: We performed a retrospective review of a prospectively maintained database of LSG performed from November 2004 to April 2007 as a one-stage primary restrictive procedure., Results: One hundred forty-eight LSGs were performed as primary procedures for weight loss. The mean patient age was 42 years (range, 13-79), mean body mass index of 43.4 kg/m(2) (range, 35-75), mean operative time of 60 min (range, 58-190), and mean blood loss of 60 ml (range, 0-300). One hundred forty-seven procedures (99.3%) were completed laparoscopically, with a mean hospital stay of 2.7 days (range, 2-25). A 2.7% major complication rate was observed with four events in three patients and no deaths. Four patients required readmission; mild dehydration in two, choledocholithiasis in one, and a gastric sleeve stricture in one., Conclusion: Laparoscopic SG is a safe one-stage restrictive technique as a primary procedure for weight loss in the morbidly obese with an acceptable operative time, intraoperative blood loss, and perioperative complication rate.

Background: Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial., Methods: A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006., Results: Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n=2; wound infection, n=2; staple-line bleed, n=1; and subcapsular splenic hematoma, n=1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients., Conclusion: Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Background: Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence of esophageal motility disorders in obese patients selected for bariatric surgery., Methods: A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure, LES relaxation, and esophageal peristalsis., Results: The study patients had a body mass index (BMI) of 42.9 kg/m2, and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia (1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain., Conclusions: Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several studies in the literature support our conclusion.

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been used increasingly more often in the past 10 years. The authors summarize their experience and safety/complications data based on 849 laparoscopic RYGBP procedures. They also evaluate the use of the Endopath trocar in terms of trocar-site hernias, bowel obstruction, and elimination of time-consuming fascial closure., Methods: From July 2000 to December 2003, 849 laparoscopic RYGBP procedures were performed using a bladeless, 12-mm, visual entry trocar. The patients' average body mass index (BMI) was 53.2 kg/m2. The trocar ports (n = 3,744) were not closed. Perioperative and postoperative assessments were performed., Results: In this study, 74% of the patients were retained for follow-up evaluation (mean, 10 months). Among these patients, no intraoperative bowel or vascular injuries, no mortality, and two trocar-site hernias (0.2%) were found. At 1 year, the mean excess weight loss was 73.4%., Conclusions: The Endopath trocar system shows a trend toward reducing trocar-site hernias, decreasing bowel obstruction, and eliminating the need for time-consuming fascial closure, although further studies are needed to confirm these findings.

Background: The purpose of this study was to determine the use of different laparoscopic approaches in the management of gastric neoplasms based on tumor type and location., Methods: We retrospectively reviewed the records of seven patients (3 men and 4 women) with 11 gastric lesions who were referred to our facility between March 2000 and October 2001 for laparoscopic excision of gastric neoplasms., Results: Two patients had gastrointestinal stromal lesions (3 lesions); two patients had hyperplastic polyps (3 lesions); one patient had carcinoid tumor (2 lesions); one patient had a carcinoma in situ and an adenoma; and one patient had an ectopic pancreas. Extraluminal laparoscopic wedge resection was used in four patients with lesions at the anterior gastric wall or along the lesser or greater curvature. Intragastric excision was used in two patients with small posterior wall lesions, and a transgastrotomy approach was used in one patient with a posterior wall lesion that could not be removed by the intragastric approach. All the lesions were completely excised with clear margins. The median hospital stay was 3 days. Complications developed in two patients. One patient presented with a perforated ulcer 2 weeks after surgery, and a second patient had postoperative pyloric edema that resolved with conservative treatment., Conclusions: The use of different laparoscopic approaches based on gastric neoplasm type and location facilitates tumor access and resection.