Search

Weight reduction continues to be first-line therapy in the treatment of hypertension (HTN). However, the long-term effect of bariatric malabsorptive surgical techniques such as Roux-en-Y Gastric Bypass (RYGB) surgery in the management of hypertension (HTN) is less clear. African Americans (AA) are disproportionately affected by obesity and hypertension and have inconsistent outcomes after bariatric surgery (BS). Despite a plethora of bariatric literature, data about characteristics of a predominantly AA bariatric hypertensive cohort including hypertension in obese (HIO) are scarce and underreported. The aims of this study were, (1) to describe the preoperative clinical characteristics of HIO with respect to HTN status and age, and (2) to identify predictors of HTN resolution one year after RYGB surgery in an AA bariatric cohort enrolled at the Howard University Center for Wellness and Weight Loss Surgery (HUCWWS). In the review of 169 AA bariatric patients, the average BMI was 48.50 kg/m 2 and the average age was 43.86 years. Obese hypertensive patients were older (46 years vs. 37.89 years; p < .0001); had higher prevalence of diabetes mellitus (DM, 43.09% vs. 10.87%; p < .0001) and dyslipidemia (38.2% vs. 13.04%; p 0.002). Hypertensive AA who were taking ≥ 2 antihypertensive medications prior to RYGB were 18 times less likely to experience HTN resolution compared to hypertensive AA taking 0-1 medications, who showed full or partial response. Also, HIO was less likely to resolve after RYGB surgery in patients who needed ≥ 2 antihypertensive medications prior to surgical intervention.

Background and Objectives: The use of laparoscopy in the trauma setting is gaining momentum, with more therapeutic procedures being performed. We evaluated the use of laparoscopic splenectomy among trauma patients with data from the National Trauma Database. We compared outcomes for trauma patients undergoing laparoscopic (LS) versus open splenectomy (OS)., Methods: From the National Trauma Database (2007 to 2015), we identified all patients who underwent a total splenectomy. Patients who had other abdominal operations were excluded. All patients were categorized into 1 of 2 groups: LS or OS. Outcomes of in-hospital mortality, postoperative length of stay, and incidence of major complications between the 2 groups were compared. Bivariate parametric and nonparametric analyses were performed. Patients were then matched on baseline demographic and injury characteristics by using propensity score matching techniques, and we compared differences by using regression analysis., Results: A total of 25,408 patients underwent OS and 113 patients underwent LS (0.44%). Patients were significantly different at baseline, with the LS group being less severely injured. Bivariate analysis revealed no difference in length of stay (9 vs 8 days, P = .62), incidence of major complications (10% vs 15%, P = .24), or mortality (6% vs 11%, P = .23). LS was performed in 29.2% of patients beyond 24 hours from presentation compared with 9.5% in the OS ( P < .001). Adjusted multivariate analysis showed no overall difference in outcomes., Conclusion: LS for trauma is increasingly being used at many centers throughout the United States. The procedure is safe, with outcomes similar to those of OS in selected trauma patients., Competing Interests: Conflicts of Interest: All authors declare no conflict of interest regarding the publication of this article.

Background and Objectives: Ureteral injury is an infrequent but potentially lethal complication of colectomy. We aimed to determine the incidence of intraoperative ureteral injury after laparoscopic and open colectomy and to determine the independent morbidity and mortality rates associated with ureteral injury., Methods: We analyzed data from the National Surgical Quality Improvement Program for the years 2005-2010. All patients undergoing colectomy for benign, neoplastic, or inflammatory conditions were selected. Patients undergoing laparoscopic colectomy versus open colectomy were matched on disease severity and clinical and demographic characteristics. Multivariate logistic regression analyses and coarsened exact matching were used to determine the independent difference in the incidence of ureteral injury between the 2 groups. Multivariate models were also used to determine the independent association between postoperative complications associated with ureteral injury., Results: Of a total of 94,526 colectomies, 33,092 (35%) were completed laparoscopically. Ureteral injury occurred in a total of 585 patients (0.6%). The crude incidence in the open group was higher than that in the laparoscopic group (0.66% versus 0.53%, P=.016). CEM produced 14 630 matching pairs. Matched analysis showed the likelihood of ureteral injury after laparoscopic colectomy to be 30% less than after open colectomy (odds ratio, 0.70; 95% confidence interval, 0.51-0.96). Patients with ureteral injury were independently more likely to have septic complications and have longer lengths of hospital stay than those without ureteral injury., Conclusion: Laparoscopic colectomy is associated with a lower incidence of intraoperative ureteral injury when compared with open procedures. Ureteral injury leads to significant postoperative morbidity even if identified and repaired during the colectomy.

Background and Objectives: Previously, risk factors for bile duct injury have been identified as acute cholecystitis, male gender, older age, aberrant biliary anatomy, and laparoscopic cholecystectomy., Methods: A retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2006 was performed with an inclusion criterion of cholecystectomy performed on hospital day 0 or 1. Patient- and hospital-level factors potentially associated with bile duct injury were examined by logistic regression., Results: A total of 377,424 cholecystectomy patients were identified. There were 1124 bile duct injuries (0.30%), with 177 (0.06%) in the laparoscopic cholecystectomy group and 947 (1.46%) in the open cholecystectomy group (P < .001). On multivariate analysis, significant risk factors for bile duct injury were male gender (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.06-1.38; P = .006), age >60 years (OR, 2.23; 95% CI, 1.61-3.09; P < .001), and academic hospital status (OR, 1.37; 95% CI, 1.05-1.79; P = .02). Acute cholecystitis was associated with a lower risk of bile duct injury (OR, 0.67; 95% CI, 0.46-0.99; P = .044)., Conclusion: Independent risk factors for bile duct injury included male gender, age >60 years, and academic hospital status. Laparoscopic cholecystectomy, obesity, insurance status, or hospital volume was not associated with an increased risk of bile duct injury.

Background: The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database., Method: The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality., Results: In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group., Conclusion: Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.

Background. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to be an effective treatment for type 2 diabetes mellitus (T2DM) in patients with morbid obesity. However, it is unclear just how effective the LRYGB procedure is on T2DM for patients with BMI less than 35 kg/m(2). We report one obese patient with T2DM who did not meet the current NIH criteria for morbid obesity surgery. This patient underwent a laparoscopic truncal vagotomy, subtotal gastrectomy, and Roux-en-Y gastrojejunostomy for intractable gastric ulcers and subsequently had full resolution of her T2DM. Methods. A 48-year-old patient with a BMI of 34.6 kg/m(2) underwent a laparoscopic truncal vagotomy, subtotal gastrectomy, and Roux-en-Y gastrojejunostomy for intractable gastric ulcers. The patient was seen 3 months preoperatively, followed for 24 months postoperatively, and evaluated for postoperative complications, weight loss, and improvement in comorbidities. Results. The patient had no postoperative surgical complications. Her BMI decreased from 34.6 kg/m(2) to 22.3 kg/m(2) by 24 months postoperatively. Significant improvements in her fasting blood glucose levels were seen 10 days postoperatively from a preoperative level of 147 mg/dl to 97 mg/dl. Conclusion. Patients with a BMI less than 35 kg/m(2) and uncontrolled T2DM may benefit from a laparoscopic Roux-en-Y gastric bypass.

Introduction: Laparoscopic adjustable gastric banding (LAGB) is a reversible method of surgical gastric restriction. Following LAGB, the adverse event most commonly necessitating subsequent reoperation is prolapse of the gastric corpus or fundus above the band. A review of the medical literature reveals no reports of nonpancreatic pseudocysts being associated with this adverse event. Nonpancreatic pseudocysts, encountered during revisional bariatric surgery should be considered a cause of irreducible gastric prolapse., Case Report: We report the case of a 41-year-old Caucasian female who underwent laparoscopic surgery to revise an adjustable gastric band and to repair an anterior gastric prolapse. Intraoperatively, 2 pseudocysts were found on the gastric fundus above the band in association with the gastric prolapse. The pseudocysts were resected, the gastric prolapse was reduced, and the band was left in place. The patient recovered uneventfully., Conclusion: Nonpancreatic pseudocysts may be associated with gastric prolapse in patients who have undergone LAGB. These pseudocysts can often be excised laparoscopically without violating the gastric lumen. This atypical presentation of gastric prolapse may pose a diagnostic and therapeutic challenge as these patients may.

Background: Postbariatric surgery poly-neuropathies (BSP) are infrequent events. However, with the number of gastric bypasses performed each year increasing, the incidence of BSP is expected to increase as well. The long-term sequelae of BSP worsen with delays in diagnoses. Therefore, early evaluation, recognition, and treatment are important in minimizing morbidity and mortality., Methods: We present the case report of a patient who developed a poly-neuropathy after a laparoscopic Roux-en-Y gastric bypass., Results: The patient's symptoms were ultimately determined to result from Guillain-Barré syndrome. Symptoms resolved with proper treatment., Conclusion: Characteristic differences exist between the various surgery poly-neuropathies. With proper evaluation, this determination will aid in prompt and appropriate treatment and will prevent morbidity and mortality.

Objective: Misidentification of ductal anatomy and electrocautery injuries are complications associated with laparoscopic cholecystectomy (LC). Dome-down LC creates a 360-degree view of the gallbladder-cystic duct junction, reducing the risk for anatomy misidentification. In addition, ultrasonic instrumentation eliminates the risk for electrocautery injuries. This study assessed the feasibility and safety of dome-down LC combined with ultrasound technology., Methods: Patients with noncancerous gallbladder disease were enrolled consecutively. Gallbladders were classified by clarity (Class I to IV) of anatomy and pathology (acute, chronic, or acalculous). The gallbladder was dissected from the gallbladder bed using a dome-down technique, and the cystic artery was coagulated and transected with the LCS-5 Harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, Ohio). The cystic duct was ligated with 2-polydioxanone Endoloops size 2-0 and sharply divided, leaving one Endoloop on the cystic duct stump., Results: LC was successfully completed in 105 patients (mean age, 44 years; range, 18 to 91 years) in whom the anatomy was classified as Class I in 30 (29%) patients, Class II in 42 (38%), Class III in 25 (24%), and Class IV in 8 (8%). Gallbladder dissection time ranged from 8 to 42 minutes (mean, 18 min). The operating room time ranged from 32 to 128 minutes (mean, 55 min). Two gallbladder perforations occurred, but no complications were associated with the extrahepatic biliary tree, viscera, or major blood vessels. Elective conversion occurred in 8 (7.6%) patients due to poor visualization of anatomy because of inflammation and adhesions. Patient blood loss was minimal in all cases. No postoperative complications were observed after a 6-month follow-up., Conclusion: Dome-down laparoscopic cholecystectomy with the LCS-5 Harmonic scalpel decreases the potential for misidentification of ductal anatomy, has minimal complications, and eliminates electrocautery risks. Conversion is related to poor visualization of anatomy due to inflammation and adhesions.

In a retrospective review of 100 consecutive cases of stab wounds to the chest, 44 patients were successfully treated with tube thoracostomy, 14 patients required thoracotomy, 17 patients with small pneumothoraces were observed, and 25 patients were asymptomatic. The overall mortality was 4%, operative mortality was 7.1%, and the mortality rate for cardiac injuries was 50%. Of the eight patients with cardiac injuries, three were dead on arrival to the hospital and one patient died in the operating room. Patients treated with tube thoracostomy had a shorter hospital stay than patients managed by observation alone. Our findings support the opinion that asymptomatic patients (normal chest x-rays) may be discharged after 24 hours of observation and asymptomatic patients with nonprogressive small pneumothoraces (less than 20%) not requiring a chest tube may be discharged after 48 hours of observation. All patients should have close outpatient follow-up.