The safety and efficacy of bariatric surgery for obese, wheelchair bound patients.

INTRODUCTION: The aim of this study was to evaluate outcomes of bariatric surgery performed in order to improve mobility in patients with severe mobility limitations. METHODS: Patients with severe mobility impairment (wheelchair bound) who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic adjustable gastric banding (LAGB) surgery to improve their mobility were included in this study. Patients were identified between July 2009 and October 2011 using an electronic prospective bariatric database. Mobility was assessed by questionnaire during clinic follow-up appointments. RESULTS: Fifteen patients (11 female, 4 male) with a mean age of 48 years (range: 26-71 years) and a mean body mass index of 46 kg/m(2) (range: 33-54 kg/m(2)) were included. Seven patients (47%) underwent LAGB and eight (53%) LRYGB. The aetiologies of mobility impairment included advanced osteoarthritis (n=6), spinal conditions (n=4), severe bilateral leg oedema and ulceration (n=2), advanced rheumatoid arthritis (n=2) and traumatic paraplegia (n=1). The mean length of hospital stay was 3.8 days. There was no mortality. One patient was lost to follow-up. Of the remaining 14 patients, the mean excess weight loss percentage at a mean of 18.5 months postoperatively was 48% (68% for LRYGB, 20 months; 29% for LAGB, 17 months). Ten patients reported improved mobility. Reduced pain, improved independence and ability to transfer were most commonly cited. Four patients reported no improvement in mobility (three LAGB patients, one LRYGB patient). CONCLUSIONS: Bariatric surgery can safely improve mobility and quality of life in obese patients with severe mobility impairment. Our paper supports the idea that severe mobility impairment should be considered an indication for bariatric surgery in selected patients. LRYGB demonstrated better weight loss and mobility improvement than LAGB. Larger studies are required to establish robust selection criteria for surgery in this group.

Comparison of weight loss achieved after laparoscopic adjustable gastric banding between Afro-Caribbean, Caucasian and South Asian adult female patients in a London bariatric centre.

INTRODUCTION: It has been shown that following laparoscopic adjustable gastric banding (LAGB) procedures, Afro-Caribbeans achieve poorer weight loss compared with Caucasians. The reasons for this are multifactorial. However, studies have been based on mainly female patients from the US and none to date have been from the UK. Furthermore, South Asians have not previously been compared. The aim of this study was to compare excess weight loss percentage (%EWL) outcomes up to five years following LAGB in Afro-Caribbean, Caucasian and South Asian females in a London-based teaching hospital. METHODS: An analysis was carried out of prospectively collected data of female patients aged ≥16 years of Afro-Caribbean, Caucasian or South Asian origin who underwent LAGB between October 2000 and December 2011. Data included demographics, co-morbidities and anthropometrics. RESULTS: Overall, 596 females underwent LAGB; 316 Caucasians (53.0%), 64 Afro-Caribbeans (10.8%) and 27 South Asians (4.5%) formed the majority of those who disclosed ethnicities. Age and initial body mass index (BMI) were comparable between Afro-Caribbeans and Caucasians (mean BMI: 47.3kg/m²[standard deviation [SD]: 7.5kg/m², range: 37.0-78.3kg/m²] vs 45.8kg/m²[SD: 7.1kg/m², range: 24.7-79.8kg/m²], p=0.225). A non-significant trend suggested less %EWL in Afro-Caribbeans than in Caucasians at 6 months, and at 1, 2, 3, 4 and 5 years (21.4% vs 24.4%, p=0.26; 27.4% vs 31.3%, p=0.27; 33.0% vs 36.8%, p=0.15; 39.0% vs 45.8%, p=0.14; 34.2% vs 45.3%, p=0.16; 37.1% vs 47.6%, p=0.67). South Asians and Caucasians had a similar age and preoperative BMI (mean BMI: 43.6kg/m² [range: 32.5-59.1kg/m²] vs 45.8kg/m² [range: 24.7-79.8kg/m²], p=0.08). The %EWL was greatest at three and four years among South Asians although numbers were small (n=4 and n=3 respectively). CONCLUSIONS: A non-significant trend suggests poorer weight loss outcomes in Afro-Caribbeans compared with Caucasians in our cohort. Discussion of realistic weight loss outcomes as well as enhanced follow-up and dietary modifications are required for Afro-Caribbean patients. Low numbers prevent definitive conclusions regarding South Asians. Multicentre studies across England are required to better define any differences between ethnicities.

Propofol sedation in a colorectal cancer screening outpatient cohort.

AIM: Colorectal cancer screening colonoscopies require sedation for both anxiety and pain. Propofol is used worldwide and allows for rapid and profound sedation with quick recovery after cessation of infusion. However, there is still a debate about whether it should be administered by anesthetists, gastroenterologists, or trained nurses. The aim of the study was to assess the number and proportion of patients who might benefit from the quality and safety of sedation under propofol during colonoscopies in a cohort of colorectal cancer screening outpatients. METHODS: Patients' genders, ages, numbers of operative procedures, and prior experience with colonoscopies were recorded, and differences were tested between sedated and unsedated patients. The need for mask ventilation and the rate of anesthetically, medically, or surgically related complications were compared between sedated and unsedated patients. The number of complete colonoscopies, length of the procedures, and time to reach the ileocecal valve were compared between sedated and unsedated patients. RESULTS: Of 135 colonoscopies, 101 were performed under sedation. All sedated patients underwent complete endoscopic examinations, while 8.9% of unsedated patients had their examination stopped due to excessive discomfort or pain. Colonoscopies tended to be shorter in sedated than unsedated patients. No anesthesia-related complications occurred. In 3/135 patients, a short period (<3 min) of mask ventilation was necessary. One surgical complication occurred among the sedated patients. One unsedated patient suffered a medical complication (dyspnea and ST-T elevation). CONCLUSIONS: Propofol sedation can be safely applied to colorectal cancer screening outpatients. Sedation was managed by a dedicated anesthetic staff and no patient suffered anesthesia-related complications.

Medical strategies for weight loss in the overweight and obese patient.

In recent years, obesity has become a major public health problem in Western countries. The World Health Organization has defined obesity as a global epidemic of the third millennium. Treatment options for weight management include dietary intervention, physical activity, behavior modification, pharmacotherapy and surgery. However, the complexity of this chronic condition necessitates a coordinated multidisciplinary team-approach to the care of obese patients who fail weight control. The long-term duration of the treatment and the necessity of monitoring compliance and effectiveness should be considered. The objective of this article was to review the major controlled randomized clinical trials dealing with the different medical strategies for weight loss and its maintenance in overweight and obese patients.

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.

BACKGROUND: The surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique. METHODS: In this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002-February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP). RESULTS: During this time, 126 patients underwent LSG (53% female). The mean age was 49.5 +/- 0.9 years, and the mean BMI was 65.3 +/- 0.8 (range 45-91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 +/- 0.3 with a median of 10 (range 3-17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 +/- 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 +/- 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 +/- 0.8 months. The mean and median hospital stays were 3 +/- 1.7 and 2.5 (range 2-7) days, respectively. There were no deaths, and the incidence of major complications was 8%. CONCLUSION: The staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

Emergent off-pump complete myocardial revascularization in dextrocardia.

Dextrocardia is a rare condition not spared by coronary artery disease. We report the case of a 72-year-old patient with dextrocardia associated with situs inversus totalis who presented to our Institution with acute myocardial infarction complicated by congestive heart failure. Due to the severe general conditions of the patient, an emergent off-pump complete myocardial revascularization was undertaken. The patient tolerated the procedure well and was asymptomatic at discharge. The technical aspects encountered in the setting of mirror-image anatomy and the advantages of off-pump myocardial revascularization in the critically ill patient are discussed.

Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks.

BACKGROUND: The adoption of advanced laparoscopic techniques for complex surgical procedures has raised the concern that the leak rate might be higher than for open surgery, particularly in the surgeon's early experience or in difficult cases. In this study, the sealing effect of fibrin glue on leaking gastrointestinal anastomoses was evaluated in an experimental swine model. METHODS: A standardized gastrojejunostomy was performed on 20 female pigs (mean weight, 47.7 +/- 5.7 kg). A leak was created on the anterior surface of the anastomosis. The animals were randomized to either fibrin glue or no treatment of the leak. Clinical conditions and vital signs, including body temperature, heart rate and, respiratory rate, were collected three times a day. Preoperative and postoperative complete and differential blood count and lactate dehydrogenase levels were determined. Postmortem analysis was performed when the animals were killed. RESULTS: Clinical signs of peritonitis developed in the control animals by the second or third postoperative day. Findings that confirmed the presence of an anastomotic leak at the postmortem examination were the presence of food or gastrojejunal juices in the abdominal cavity, a localized abscess, or a positive air leak test. Fibrin glue treatment prevented the development of peritonitis in all the animals. Complete sealing of the leak was observed on postoperative day 7 in all treated animals, except one in which an asymptomatic contained leak developed. The postoperative total white blood count was significantly increased in the untreated group (24.69 +/- 5.5 vs 12.74 +/- 3.7 10(3)/ul p < 0.001, paired t-test), as compared with the treated group (15. 55 +/- 2.4 vs 14.89 +/- 2.7 10(3)/ul; p = 0.24). CONCLUSION: In this study, fibrin glue showed reproducible sealing effects on leaking gastrojejunal anastomoses. Fibrin glue application may be a valuable approach for the treatment of gastrointestinal anastomotic leaks.

Surgical endarterectomy for suprarenal iliac artery stenosis in renal allograft recipient.

Aortoiliac surgery performed in renal transplant recipients carries the risk of inducing a prolonged period of ischemia that can threaten organ survival. Recently, endovascular techniques have been increasingly applied but the rate of complications and recurrences remains significant. We report the case of a kidney heterotopic allotransplant recipient who presented with a history of new-onset arterial hypertension, right lower limb claudication, and allograft dysfunction related to a long, eccentric, and ulcerated plaque causing hemodynamic stenosis of suprarenal iliac artery that was successfully managed with surgical endarterectomy. Despite new advances in less invasive procedures such as transluminal angioplasty and stent implantation, surgical endarterectomy of suprarenal iliac artery may be safely performed in selected heterotopic kidney transplant recipients. It allows for complete removal of the plaque, with better long-term results, and does not preclude subsequent endovascular or surgical procedures; therefore it should be considered a therapeutic option in this clinical setting.

Combined percutaneous and surgical approach to a postnephrectomy arteriovenous fistula.

The case of a patient with long-standing severe heart failure that was ultimately found to be secondary to a large communication between the right renal artery stump and the inferior vena cava is reported. The occurrence of an arteriovenous fistula should be suspected in patients who underwent previous nephrectomy since early diagnosis would avoid relevant cardiac complications and the demise of a patient suffering from a disease that may be corrected surgically or percutaneously. We describe a combined approach that allowed the percutaneous decompression of the inferior vena cava and relief of the volume overload to the heart prior to the surgical ligation of the arteriovenous fistula. This approach should be considered a valuable option for treating long-standing high output postnephrectomy arteriovenous fistulas.

Spiral CT virtual endoscopy of abdominal arteries: clinical applications.

Virtual endoscopy enables the creation of endoluminal views of the aorta and its branches by processing spiral computed tomographic (CT) images, thereby allowing the preoperative and postoperative evaluations of abdominal aortic aneurysms, aneurysms of the splenic, celiac, and common iliac arteries, and renal artery stenoses. Moreover, it is helpful for verifying the position of stents and endoprostheses from within the aortic lumen. This method is a promising addition to spiral CT.

External jugular vein hemangioma occurring as a lateral neck mass.

Hemangioma is an extremely frequent tumor, accounting for 7% of all benign neoplasms. In contrast, hemangioma arising in blood vessels is rare and should be differentiated from other neoplasms of vascular origin, such as hemangioendothelioma, hemangiopericytoma, hemangiosarcoma, and leiomyosarcoma. The case we report has the peculiarity of occurring as a lateral neck mass in which color-coded duplex sonography contributed significantly to diagnosis.

Surgical closure of muscular ventricular septal defects using double umbrella devices (intraoperative VSD device closure).

OBJECTIVES: Surgical closure of some muscular ventricular septal defects has been proven to be difficult. In order to simplify the surgical technique we have used intraoperatively Rashkind double umbrella devices to occlude muscular ventricular septal defects. METHODS: On the basis of haemodynamic and echocardiographic study five children aged 4, 6, 7, 14 and 41 months were considered suitable candidates for intraoperative closure of muscular ventricular septal defects (midmuscular in three cases, apical in two) by Rashkind devices. Three of them had previously undergone pulmonary artery banding at 10, 11 and 41 days, respectively. During hypothermic cardiopulmonary by pass a delivery system was introduced across the tricuspid valve into the right ventricle and then passed through the ventricular septal defect; the distal umbrella of a 17 mm device was opened in the left ventricular cavity; a traction was applied to the introducer and the proximal umbrella was opened on the right side straddling the interventricular septum; the device was then secured on the right side by few stitches. In one case because of the wide diameter of the ventricular septal defect two umbrellas were used. The surgical procedure was completed with debanding and/or closure of other defects close to the aortic or tricuspid valve. RESULTS: Immediate results, tested by epicardial or transesofageal echo, showed a minimal residual shunt in 4 patients and a moderate shunt in one. No early deaths occurred. A complete atrioventricular block developed in 1 patient who had an additional perimembranous defect closed with a prosthetic patch: a permanent pace maker was inserted 3 months after the operation. There was a late death for untractable right ventricular failure in 1 patient who had a large residual shunt erroneously considered moderate. In this patient, the size of the defect was underestimated both preoperatively then intraoperatively. The four survivors are doing well with no signs of hemodynamically significant residual shunts. CONCLUSIONS: The use of Rashkind umbrella devices for closing intraoperatively muscular defects can be helpful to standard surgical techniques when technical problems make patch closure difficult. Its use avoid the need of left ventriculotomy. Careful definition of the size of the defect is mandatory to select suitable candidates.