Tension pneumocephalus following bariatric surgery: case report.

Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.

Revisional operations for marginal ulcer after Roux-en-Y gastric bypass.

BACKGROUND: Marginal ulcer is a potentially serious complication of Roux-en-Y gastric bypass (RYGB). This study reviewed 1 surgeon's experience with 39 revisional operations for intractable marginal ulcer after primary RYGB. METHODS: A total of 2282 consecutive patients underwent RYGB by 1 surgeon from 1984 to 2006, of which 1621 were open and 661 laparoscopic. The stomach was transected in laparoscopic RYGB and was left undivided in the open group. All revisions included ulcer excision, revision of the gastrojejunostomy with gastric transection as needed. Six patients underwent vagotomy. RESULTS: Of the 2282 patients, 122 (5.3%) developed marginal ulcers (88 and 34 from the open and laparoscopic group, respectively). Of these 122 patients, 39 (32%) underwent revision for intractability (35 open and 4 laparoscopic). Of these 39 patients, 28 (71.7%) had gastrogastric fistulas. Risk factors for ulcer (medication, smoking) were present in 26 patients (66.6%). The primary indications of intractability included abdominal pain (66.6%), gastrointestinal bleeding (20.5%), stomal obstruction (10.2%), and perforation (2.5%). Early postoperative complications included 2 leaks (5.1%) and 2 wound infections (5.1%). Three smokers (7.7%) developed recurrent ulcers postoperatively. One patient died of acute respiratory distress syndrome 5 months postoperatively. Of the 39 patients, 34 (87%) remained asymptomatic after revision. The revision rate was significantly less after laparoscopic RYGB (.6%) than after open RYGB (2.1%; P < or =.0025). CONCLUSION: The results of our study have shown that operations for intractable marginal ulcer after RYGB are highly successful in nonsmokers. Patients who undergo laparoscopic RYGB with gastric transection are less likely to require revision than patients who undergo RYGB with an incontinuity gastric partition. The rate of reoperation for marginal ulcer was greater than anticipated.

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Mesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population. METHODS: The records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO. RESULTS: Of the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus. CONCLUSION: SBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.