Laparoscopic Handsewn Gastrojejunostomy Revision of Gastrojejunal Anastomosis with Takedown of Gastro-gastric Fistula.

BACKGROUND: Marginal ulcer (MU) and gastro-gastric fistula (GGF) are well-described complications following Roux-en-Y gastric bypass (RYGB). The incidence of MU ranges from 0.6 to 25% and the incidence of GGF following divided RYGB has been reported as high as 6%. MU has been shown to be associated with GGF with a 53% incidence of MU in patients with GGF versus 4% in patients without GGF. Other risk factors for developing GGF previously identified in the literature include incomplete gastric transection, staple-line leak, and foreign body erosion. Management of GGF begins with aggressive medical therapy aimed at decreasing acid production, and surgical intervention is indicated for persistent symptoms such as weight gain or persistent ulcers. Endoscopic therapy is not recommended given risk of failure in setting of chronic inflammation. METHODS: To demonstrate the operative management of gastro-gastric fistula from chronic marginal ulcer. A 52-year-old female who had previous robotic RYGB in 2012 developed a chronic marginal ulcer and was diagnosed with a gastro-gastric fistula in 2017. She had a suspected perforation of her marginal ulcer in 2018, although no ulcer was found on laparoscopic exploration. She was taken to the OR for revision in 2018 for chronic marginal ulcer and strictures. Two gastro-gastric fistulas were found and resected, and a redo gastrojejunostomy was performed. RESULTS: We used a handsewn RYGB technique in this patient, and other options include circular or linear techniques to create the gastrojejunal anastomosis [GJA]. We have found the rate of both stricture and marginal ulcer higher after circular stapled GJA technique. She did well post-operatively and did not have any further issues with marginal ulcers or strictures. CONCLUSIONS: A significant number of patients with GGF will fail maximal medical therapy and will require surgical treatment. Laparoscopic resection of GGF is the most well-described surgical technique, with or without revision of the gastrojejunostomy depending on presence of anastomotic stricture, marginal ulcer, or involvement with GG fistula. Surgical therapy has been shown to lead to good outcomes.

Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration.

PURPOSE: Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics. MATERIAL AND METHODS: Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed. RESULTS: In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0-108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm3). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm3 increase in pouch size, patients had 2.4 times odds increase of MU formation. CONCLUSIONS: CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.

Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy.

INTRODUCTION: Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP. METHODS: Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used. RESULTS: In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02). CONCLUSIONS: In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.

Diagnosis and Management of Parastomal Hernias.

CASE SUMMARY: A 63-year-old woman with history of stage II rectal adenocarcinoma status postneoadjuvant chemoradiation and subsequent abdominoperineal resection presented with worsening bulge and inability to pouch stoma. CT scan revealed a 4-cm parastomal hernia. After discussion with the patient regarding management options, she elected to undergo repair of hernia defect. A robot-assisted laparoscopic parastomal hernia repair with synthetic mesh via the Sugarbaker technique was performed. After a short stay in the hospital, the patient recovered well and reported no recurrent symptoms.

Opioid prescription practices at discharge and 30-day returns in children with sickle cell disease and pain.

BACKGROUND: Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. We examined prescription practices at the time of discharge in children with SCD presenting with acute pain to determine their impact on 30-day emergency department (ED) revisits and readmissions. METHODS: In this single-institution, 5-year retrospective study, we reviewed 290 encounters of patients with SCD aged 7-21 years hospitalized or discharged from the ED with acute pain. We reviewed demographic, treatment and discharge data, and 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Bivariate and multivariable analyses were performed to evaluate the association between discharge prescription practices and 30-day returns. RESULTS: Compared to hospitalizations, treat-and-release ED visits for acute pain were associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI: 1.5-4.8], P < 0.01). We found no association between prescribed opioid frequency (scheduled vs. as-needed) and 30-day returns (OR = 1.12 [95% CI: 0.62-2.02], P = 0.70). By multivariable logistic regression, the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) only, without opioids, after treat-and-release ED visits was independently associated with a higher frequency of 30-day ED revisits (OR = 6.9 [95% CI: 1.3-37.3], P = 0.03) but not readmissions. CONCLUSION: Variability exists in opioid prescription practices after discharge in children with SCD and pain episodes. Prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence returns, including outpatient opioid management, are warranted in this population.

Bladder Pneumatosis From a Catastrophic Vascular Event.

Air within the bladder wall, or bladder pneumatosis, is a very rare finding typically resulting from an infectious etiology, as in emphysematous cystitis (EC). However, there have been reports of bladder pneumatosis occurring without clear infectious origins. We present a case of a female patient found to have concurrent bladder and ileal pneumatosis secondary to a catastrophic vascular event. Prompt recognition of non-infectious etiologies of bladder pneumatosis is essential as this distinction may dramatically alter clinical decision-making.

Lower Urinary Tract Symptoms Secondary to Mass Lesion of the Brain: A Case Report and Review of the Literature.

Lower urinary tract symptoms (LUTS) secondary to neurologic disorders are well-established, but intracranial mass lesions are rare causes of LUTS with very few case reports described in the literature. We present a 28-year old man with urinary urgency, frequency and incontinence which were revealed to be secondary to a large thrombosed intracranial aneurysm. Any unusual clinical presentations of LUTS such as new onset neurologic symptoms need to be explored to rule out potentially treatable causes.