Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy.

Background and Objectives: Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure. Methods: A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019. Results: A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15-95 days). Conclusion: Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.

Laparoscopic management of presacral myelolipoma.

Myelolipomas are rare, benign nonfunctioning tumors, most commonly found in the adrenal glands. At least 43 cases of extra adrenal myelolipomas have been reported, with at least 50% of these reported cases occurring in the presacral region. Herein we report a case of presacral myelolipoma managed laparoscopically.

Polyester composite versus PTFE in laparoscopic ventral hernia repair.

INTRODUCTION: Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair. METHODS: A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit. RESULTS: Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS). CONCLUSION: Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.

Factors that predict outcome of abdominal operations in patients with advanced cirrhosis.

BACKGROUND & AIMS: Patients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management. METHODS: A retrospective review was performed of 100 cirrhotic patients (50 classified as Child-Turcotte-Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002-2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome. RESULTS: The overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score >or=15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score >or=15 and albumin 2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015). CONCLUSIONS: For patients with MELD scores >or=15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Comparison of comorbidity resolution and improvement between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding.

BACKGROUND: This study aimed to compare the rates for resolution and improvement of common comorbidities between laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding. The comorbid conditions included were type 2 diabetes mellitus (DM), hypertension (HTN), hyperlipidemias (LPD), degenerative joint disease (DJD), gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and asthma. METHODS: A retrospective chart review of the patients who underwent LSG or laparoscopic adjustable gastric banding at our institution from July 2004 to July 2007 was performed. The resolution of comorbidities was determined via patient-completed questionnaires and objective data. RESULTS: Of the 123 patients (29 men and 94 women) reviewed, 49 had undergone LSG, and 74 had undergone laparoscopic adjustable gastric banding. The mean preoperative body mass index (BMI) was 52 kg/m(2) for the LSG patients and 44 kg/m(2) for the laparoscopic adjustable gastric banding patients. The overall percentages of excess weight loss (%EWL) were respectively 50.6 and 40.3% (P = 0.03) during mean follow-up periods of 15 and 17 months. There was a greater resolution or improvement of DM after LSG (100% vs 46%), HTN (78% vs 48%), and LPD (87% vs. 50%) than after laparoscopic adjustable gastric banding. Other comorbidities resolved or improved at a similar rate. CONCLUSIONS: Although both LSG and laparoscopic adjustable gastric banding resulted in postoperative improvement or resolution of comorbidities associated with obesity, LSG statistically showed a significantly higher rate of resolution or improvement of DM, HTN, and LPD. There was no significant difference between the groups for DJD, GERD, OSA, or asthma.

Laparoscopy: a safe approach to appendicitis during pregnancy.

BACKGROUND: The aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy. METHODS: A hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson's chi(2) test, Fisher's exact test, Mann-Whitney test, and Kruskal-Wallis test. RESULTS: Of the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, p < 0.001) and second trimesters (73% vs. 27%, p < 0.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, p = NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2 days, p = 0.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38 degrees C, leukocytosis greater than 16 x 10(9)/l, or more than 48 h between onset of symptoms and emergency room presentation. CONCLUSIONS: This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.

Laparoscopic and open reversal of Hartmann's procedure--a comparative retrospective analysis.

BACKGROUND: Restoration of intestinal continuity after Hartmann's procedure has traditionally required laparotomy. This study compares our experience with laparoscopic and open reversal of Hartmann's procedure. STUDY DESIGN: All laparoscopic and open Hartmann's reversal procedures performed between January 1998 and June 2006 were reviewed. Patients with laparoscopic reversal were retrospectively matched by age, body mass index (BMI), and indication to controls with open reversal. Demographic data, perioperative course, and postoperative complications were documented. RESULTS: We identified 41 patients who underwent laparoscopic reversal of Hartmann's procedure and these were matched to 41 patients with open reversal. The groups had similar average age and BMI. The predominant indication for surgery in both groups was diverticular disease. Conversion to laparotomy occurred in eight patients (19.5%), and was due to dense adhesions or difficulty in identification of the rectal stump. Adhesions were significantly greater in the conversion group (p <0.05), and the rectal stump was not marked in any of these cases. The most common short-term complications were ileus and surgical site infection. There were no anastomotic leaks and no mortalities. The mean operative times in the laparoscopic and open groups were 193 versus 209 min, respectively (p = 0.33). The laparoscopic group had a significantly lower estimated blood loss of 166 versus 326 mL (p < 0.0005), shorter time to bowel function return (4.1 versus 5.2 days, p < 0.05), and a shorter hospital stay (6.4 versus 8.0 days, p < 0.05). The major complication rate was also significantly lower in the laparoscopic group than in the open group (4.8% versus 12.1%, p < 0.05). CONCLUSIONS: Laparoscopic reversal of Hartmann's procedure is a safe and practical alternative to open reversal. It can be performed with similar operative time, fewer complications, and a faster recovery time. Conversion during the reversal procedure was significantly impacted by severity of adhesions and marking of the rectal stump.

Laparoscopic resection of giant adrenal cavernous hemangioma.

BACKGROUND: Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy. METHODS: Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass. RESULTS: The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland. CONCLUSION: The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.

Recurrence after laparoscopic ventral hernia repair: a prospective pilot study of suture versus tack fixation.

Mesh fixation in laparoscopic ventral hernia repair requires the use of tacks and/or permanent transabdominal sutures. Sutures pass through all fascial and muscle layers of the anterior abdominal wall, whereas tacks secure the mesh simply to peritoneum. Controversy exists regarding the optimal fixation method. In this pilot study, we compared recurrence rates between these two techniques. Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively and nonrandomly enrolled in the study and underwent either suture-fixation or tack-fixation. Office charts, computed tomography, and telephone interviews were used to determine recurrence events. chi2 and Student's t tests were performed to compare group characteristics and multivariate Cox regression analysis was used to assess for recurrence predictors after adjusting for potential confounders. From 2004 to 2005, 27 patients had suture repairs and 21 had tack repairs. The two groups had similar demographic, history, and operative variables. At a mean follow-up of 18 months, the recurrence rate was 14 per cent. In multivariate analyses, fixation method did not significantly affect recurrence. In this pilot study, patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experienced similar recurrence rates. Future studies will be needed to validate these findings.

Postoperative pain after laparoscopic ventral hernia repair: a prospective comparison of sutures versus tacks.

BACKGROUND AND OBJECTIVES: Mesh fixation in laparoscopic ventral hernia repair typically involves the use of tacks, transabdominal permanent sutures, or both of these. We compared postoperative pain after repair with either of these 2 methods. METHODS: Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively enrolled in the study. They were sorted into 2 groups (1) those undergoing hernia repairs consisting primarily of transabdominal suture fixation and (2) those undergoing hernia repairs consisting primarily of tack fixation. The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively. RESULTS: From 2004 through 2005, 50 patients were enrolled in the study. Twenty-nine had hernia repair primarily with transabdominal sutures, and 21 had repair primarily with tacks. Both groups had similar average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. Both groups also had similar times to return to work and need for narcotic pain medication. CONCLUSIONS: Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar postoperative pain. The choice of either of these fixation methods during surgery should not be based on risk of postoperative pain.

Internal hernias: clinical findings, management, and outcomes in 49 nonbariatric cases.

Internal hernia, the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. We report the clinical presentation, surgical management, and outcomes of one of the largest series of nonbariatric internal hernias. Ten-year retrospective review of patients at our institution yielded 49 cases of internal hernias. Majority of patients presented with symptoms of acute (75%) or intermittent (22%) small bowel obstruction. While 16% of CT scans were suspicious for internal hernia, in no cases the preoperative diagnosis of internal hernia was made. The most frequent internal hernias were transmesenteric (57.0%) and 34 hernias (69%) were caused by previous surgery. All internal hernias were reduced and the defects were repaired. Compromised bowel was present in 22 cases and 11 patients underwent small bowel resection. The mean postoperative hospitalization was 10.9 days. The overall mortality rate from our series is 2%, and the morbidity rate is 12%. Transmesenteric hernias, as complications of previous surgeries, are the most prevalent internal hernias. Preoperative diagnosis of internal hernia is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, internal hernias can be repaired with acceptable morbidity and mortality.

Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality.

BACKGROUND: Pneumatosis intestinalis (PI) is an unusual finding that can exist in a benign setting but can indicate ischemic bowel and the need for surgical intervention. We present a series of cases of PI in adults to illustrate factors associated with death and surgical intervention. METHODS: We reviewed the radiology database of the Mount Sinai Medical Center for cases of PI between 1996-2006 in adult patients. Chi-square and multivariable logistic regression analyses were used to identify factors significant for surgery and death. RESULTS: Forty patients developed PI over a 10-year span. The overall in-hospital mortality rate was 20%, and the surgical rate was 35%. Factors independently associated with surgical management on multivariable analysis were age >or= 60 years (p = 0.03), the presence of emesis (p = 0.01), and a WBC > 12 c/mm3 (p = 0.03). Pre-existing sepsis was independently associated with mortality (p = 0.03) while controlling for surgery. CONCLUSION: Patients with the concomitant presence of PI, a WBC > 12 c/mm3, and/or emesis in the >60-year-old age group were most likely to have surgical intervention, whereas PI patients with sepsis had the highest risk for death. A management algorithm is proposed, but further research will be needed to determine which patients with PI may benefit most from surgery.

Comparison of iatrogenic splenectomy during open and laparoscopic colon resection.

Iatrogenic splenic injury requiring splenectomy is a well-recognized and potentially serious complication of colon resection. Iatrogenic splenectomy is associated with significant morbidity and mortality, including bleeding and the postsplenectomy sepsis syndrome. Our study aims to compare the incidence of iatrogenic splenectomy in laparoscopic colon resection with that of open colon resection over an 11-year-period at Mount Sinai. A retrospective chart review of all patients undergoing colon resection at Mount Sinai Medical Center during the last 11 years was performed to identify patient demographics, procedure, indication, and outcome. There was a significant difference (P=0.03) in the incidence of iatrogenic splenectomy during open colectomy (13/5477, 0.24%) versus laparoscopic colectomy (0/1911, 0%). All cases complicated by iatrogenic splenectomy involved splenic flexure mobilization. Laparoscopy has many recognized advantages over open procedures, including shorter recovery and length of stay. This retrospective review of our experience at Mount Sinai presents another potential benefit of the laparoscopic approach to colon resection.

Laparoscopic resection of gastrointestinal stromal tumors: Does laparoscopic surgery provide an adequate oncologic resection?

Gastrointestinal stromal tumors (GISTs) are rare tumors of the GI tract. Surgical resection remains the mainstay of non-metastatic disease. However, the ability to provide an adequate oncologic resection using laparoscopic surgery is still an area of debate. This is a thorough review of the current literature, looking particularly at the use of laparoscopic surgery for larger GISTs and the long-term oncologic outcomes compared to the results of open surgery. Laparoscopic resections provide an adequate oncologic result for GISTs of all sizes, including those greater than 5 cm in size.

Laparoscopic surgery for diverticular disease complicated by fistulae.

OBJECTIVES: Elective laparoscopic surgery for recurrent, uncomplicated diverticular disease is considered safe and effective; however, little data exist on complicated cases. We investigated laparoscopic sigmoid resection for diverticulitis complicated by fistulae. METHODS: We conducted a retrospective review of patients who underwent laparoscopic treatment of enteric fistulae complicating diverticular disease performed by 4 surgeons at the Mount Sinai Medical Center. RESULTS: From 1994 to 2004, 14 patients underwent elective laparoscopic sigmoid resections for diverticular disease complicated by enteric fistulae. Patients' mean age was 62 and 4 were female. Multiple fistulae were present in 21%. Types of fistulae included 8 colovesical, 5 enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous. All patients successfully underwent sigmoidectomy, and 14% required additional bowel resections. No cases were proximally diverted. Conversion to open was necessary in 36% of cases, all due to dense adhesions and severe inflammation. The mean operative time was 209 minutes, and the mean blood loss was 326 mL. Two (14%) postoperative complications occurred, including one anastomotic bleed and one prolonged ileus. No anastomotic leaks or mortalities occurred. The mean postoperative stay was 6 days. CONCLUSION: Laparoscopic management of diverticular disease complicated by fistulae can be performed effectively and safely. The conversion rate is higher than traditionally accepted rates of uncomplicated cases of diverticulitis and is associated with severe adhesions and inflammation.

Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR. STUDY DESIGN: Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively. RESULTS: Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05). CONCLUSIONS: Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients.

Laparoscopic surgery in the management of Crohn's disease.

Crohn's disease is a chronic inflammatory bowel disease with surgery still frequently necessary in its treatment. Since the 1990's, laparoscopic surgery has become increasingly common for primary resections in patients with Crohn's disease and has now become the standard of care. Studies have shown no difference in recurrence rates when compared to open surgery and benefits include shorter hospital stay, lower rates of wound infection and decreased time to bowel function. This review highlights studies comparing the laparoscopic approach to the open approach in specific situations, including cases of complicated Crohn's disease.