Giant inguinal hernia repair using standard transverse inguinal incision with mesh. A retrospective case control study.

BACKGROUND: Giant inguinal hernia (GIH) is a rare condition in the developed world, and the literature is scarce. Case reports describe different techniques in an attempt to prevent abdominal compartment syndrome (ACS). We aimed to review our experience with GIH repair. METHOD: A retrospective review of the medical records of all consecutive patients who underwent a tension-free mesh GIH repair using a transverse inguinal incision between 2014 and 2021 at a tertiary university referral center. In brief, the technique included head-down positioning, maximal pre-incision reduction of hernia contents, and repair with mesh. Follow-up was conducted in outpatient clinic. We compared the results to a time-based open standard inguinal hernia repair group (control group). RESULTS: During the study period, 58 patients underwent an open GIH repair with mesh without abdominal preparation. 232 patients were included in the control group. The mean surgery duration was 125.5 min in the GIH group and 84 min in the control group (p < 0.001). Bowel resection was not necessary in any case. In-hospital complication rates were 13.8% vs. 5.6% in the GIH and control groups, respectively (p = 0.045). Early complication rates (up to 30 days post-operatively) were 62.1% vs. 14.7% in the GIH and control groups, respectively (p < 0.001). Late complications rate was similar (p = 0.476). ACS and mortality were not reported. No recurrence event was reported in the GIH group. CONCLUSION: Tension-free mesh repair for GIH using a standard transverse inguinal incision is feasible and safe and there is no need for abdominal cavity preparation. Early complications are more common than in the control group, but there were no higher rate of late or severe complications and no recurrence event.

Effect of Magnetic Resonance Imaging on Acute Surgical Treatment of Pregnant Patients: A Single Institution Study.

BACKGROUND: Abdominal pathology in pregnant patients is a frequent challenge for emergency department physicians. Ultrasound is the imaging modality of choice but is inconclusive in approximately one-third of cases. Magnetic resonance imaging (MRI) is becoming increasingly available, even in acute settings. Multiple studies have defined the sensitivity and specificity of MRI in this population. OBJECTIVES: To evaluate the use of MRI findings in pregnant patients presenting with acute abdominal complaints to the emergency department. METHODS: This retrospective cohort study was conducted at a single institution. Data were collected on pregnant patients who underwent an MRI for acute abdominal complaints between 2010 and 2019 at a university center. Patient demographics, diagnosis at admission, ultrasound and MRI findings, and discharge diagnosis were recorded and evaluated. RESULTS: In total, 203 pregnant patients underwent an MRI for acute abdominal complaints during the study period. MRI was found without pathology in 138 cases (68%). In 65 cases (32%), the MRI showed findings that could explain the patient's clinical presentation. Patients presenting with long-standing abdominal pain (> 24 hours), fever, leukocytosis, or elevated C-reactive protein values were at a significantly increased risk of having an acute pathology. In 46 patients (22.6%), MRI findings changed the primary diagnosis and management while in 45 patients (22.1%) MRI findings improved characterization of the suspected pathology. CONCLUSIONS: MRI is helpful when clinical and sonographic findings are inconclusive, leading to changes in patient management in more than one-fifth of patients.

Psoas Attenuation and Mortality of Elderly Patients Undergoing Nontraumatic Emergency Laparotomy.

BACKGROUND: Emergency laparotomy (EL) is an increasingly common procedure in the elderly. Factors associated with mortality in the subpopulation of frail patients have not been thoroughly investigated. Sarcopenia has been investigated as a surrogate for frailty and poor prognosis. Our primary aim was to evaluate the association between easily measured sarcopenia parameters and 30-day postoperative mortality in elderly patients undergoing EL. Length of stay (LOS) and admission to an intensive care unit were secondary end points. METHODS: We conducted a retrospective cohort study, over a 5-year period, of patients aged 65 y and older who underwent EL at a tertiary university hospital. Sarcopenia was evaluated on admission computed tomography scan by two methods, first by psoas muscle attenuation and second by the product of perpendicular cross-sectional diameters (PCSDs). The lowest quartile of PCSDs and attenuation were defined as sarcopenic and compared with the rest of the cohort. Attenuation was stratified for the use of contrast enhancement. Multivariant logistic regression was performed to determine independent risk factors. RESULTS: During the study period, 403 patients, older than 65 y, underwent EL. Of these, 283 fit the inclusion criteria and 65 (23%) patients died within 30 d of surgery. On bivariate analysis, psoas muscle attenuation, but not PCSDs, was found to be associated with 30-day mortality (OR = 2.43, 95% CI = 1.34-4.38, P = 0.003) and longer LOS (35.7 d versus 22.2 d, Δd 13.5, 95% CI = 6.4-20.7, P < 0.001). In a multivariate analysis, psoas muscle attenuation, but not PCSDs, was an independent risk factor for 30-day postoperative mortality (OR = 2.35, 95% CI = 1.16-4.76, P = 0.017) and longer LOS (Δd = 14.4, 95% CI = 7.7-21.0, P < 0.001). Neither of the sarcopenia parameters was associated with increased admission to an intensive care unit. DISCUSSION: Psoas muscle attenuation is an independent risk factor for 30-day postoperative mortality and LOS after EL in the elderly population. This measurement can inform clinicians about the operative risk and hospital resource utilization.

Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change?

BACKGROUND: Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center. MATERIALS AND METHODS: A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications. RESULTS: A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57 ± 0.6 years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9 ± 0.2, 1.5 ± 0.1, and 3.4 ± 0.2 days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97 ± 9.8 days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6 ± 0.2 days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications. CONCLUSIONS: Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.

Endovascular management of blunt renal artery trauma.

BACKGROUND: Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported. OBJECTIVES: To present our experience with endovascular management of blunt renal artery injury, and review the literature. METHODS: We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications. RESULTS: Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered. CONCLUSIONS: Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.

Posttraumatic stress disorder in hospitalized terrorist bombing attack victims.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a psychiatric disorder that results from exposure to a traumatic event and consists of intrusive and unwanted recollections; avoidance followed by emotional withdrawal; and heightened physiologic arousal. Hospitalized victims of suicide bombing attacks (SBAs) are unique because of the circumstances and severity of their injuries, which could affect the occurrence and delay the recognition of PTSD. Our objectives were to evaluate the prevalence and severity of PTSD among hospitalized SBA victims and to assess variables of physical injury as risk factors for the development of PTSD. METHODS: Forty-six hospitalized SBA victims were evaluated for PTSD using the PTSD symptom scale self-report questionnaire by phone. Demographic and medical data regarding the severity and type of injury and medical treatment were collected from medical files. Injury Severity Score was used to assess severity of physical injury. RESULTS: Twenty-four of 46 (52.2%) hospitalized SBA victims developed PTSD. Presence of blast lung injury was significantly higher in the PTSD group compared with the non-PTSD group (37.5% versus 9.1%, respectively; p < 0.04). There was no significant difference in Injury Severity Score between PTSD and non-PTSD groups. Blast lung injury and intracranial injury were found to be positive predictors of PTSD (odds ratio, 125 and 25, respectively). No correlation was found between the length of stay, length of intensive care unit stay, or severity of physical injuries and the severity of PTSD. CONCLUSIONS: Hospitalized victims of SBA are considerably vulnerable to develop PTSD. Victims should be monitored closely and treated in conjunction with their physical treatment. Blast lung injury and intracranial injury are predictors of PTSD.

The pattern of thoracic trauma after suicide terrorist bombing attacks.

BACKGROUND: The worldwide escalation in the volume of suicide terrorist bombing attacks warrants special attention to the specific pattern of injury associated with such attacks. The goal of this study was to characterize thoracic injuries inflicted by terrorist-related explosions and compare pattern of injury to penetrating and blunt thoracic trauma. METHODS: Prospectively collected database of patients with chest injury who were admitted to Hadassah Hospital Level I trauma centre, in Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into three groups according to the mechanism of injury: terrorist explosions (n = 55), gunshot wounds (GSW; n = 78), and blunt trauma (n = 747). RESULTS: There were many female victims after suicide bombing attacks (49.1%) compared with GSW (21.8%) and blunt trauma (24.6%; p = 0.009). The number of body regions injured was significantly higher in the terror group compared with the GSW and blunt groups (median, 4, 2, and 3, respectively, p < 0.0001). The pattern of chest injury after suicide bombing attacks was caused by a unique combination of the effects of the blast wave and penetrating shrapnel. More than half (52.7%) of the terror victims suffered from lung contusion and 25 (45.5%) required tube thoracostomy. Five patients (9.1%) underwent thoracotomy for lung lacerations (n = 3), injury to great vessels (n = 2), cardiac lacerations (n = 1), and esophageal injury (n = 1). Penetrating shrapnel was the mechanism of injury in all these cases. CONCLUSIONS: Injury inflicted by terrorist bombings causes a unique pattern of thoracic wounds. Victims are exposed to a combination of lung injury caused by the blast wave and penetrating injury caused by metallic objects.

Single-trocar cholecystectomy using a flexible endoscope and articulating laparoscopic instruments: a bridge to NOTES or the final form?

INTRODUCTION: NOTES cholecystectomy, may eliminate complications related to abdominal incisions. However, the nonmandatory gastrotomy and its safe closure is the main controversy accompanying this approach. Transvaginal access has minimal closure consequences but the safety of inserting extralong instruments between the intestines and having the angle of approach from below rather than from above is questionable. We conducted a study for performing cholecystectomy using a single laparoscopic trocar. METHODS: The single-trocar cholecystectomy technique was developed on five porcine animal models weighing 35-40 kg each. A 15-mm trocar was used, inserted transumbilicaly. Retraction of the gallbladder was achieved using an endoloop and transabdominal anchoring. Hartman's pouch was manipulated with an endoscopic grasper, which was passed through the working channel of the endoscope, while dissection of the triangle of Callot was performed using articulating laparoscopic instruments. RESULTS: Single-trocar cholecystectomy was successfully performed in four of five porcine models. Average surgery time was 90 min (35-180 min). The technique was modified and improved throughout the study. No intraoperative complications occurred. CONCLUSIONS: Single-trocar cholecystectomy is feasible and offers safe approach to this procedure. We assume that a single incision at the umbilicus generates minimal somatic pain, and achieves excellent cosmetic results. The translation of this technique to human subjects seems straightforward and raises the question of whether NOTES is the preferred technique for cholecystectomy.

Conservative treatment for acute cholecystitis: clinical and radiographic predictors of failure.

BACKGROUND: Current treatment options for acute calculous cholecystitis include either early cholecystectomy, or conservative treatment consisting of intravenous antibiotics and an interval cholecystectomy several weeks later. Percutaneous drainage is reserved for patients in whom conservative therapy failed or as a salvage procedure for high risk patients. OBJECTIVE: To identify clinical and radiographic factors leading to failure of conservative treatment. METHODS: We prospectively collected data on consecutive patients admitted with the diagnosis of acute cholecystitis. Parameters were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy. Logistic regression analysis was performed to identify predictors for failure of conservative treatment. RESULTS: The study population comprised 103 patients with a median age of 60 who were treated for acute cholecystitis. Twenty-seven patients (26.2%) required PC. On univariate analysis, age above 70 years, diabetes, elevated white blood cell count, tachycardia (> 100 beats/min) at admission, and a distended gallbladder (> 5 cm transverse diameter) were found to be significantly more common in the PC group (P < 0.001). WBC was higher in the PC group throughout the initial 48 hours. On multivariate analysis, age above 70 (odds ratio 3.6), diabetes (OR 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder (OR 8.5) were predictors for cholecystostomy (P < 0.001). Age above 70 (OR 5.2) and WBC $15,000 (OR 13.7) were predictors for failure of conservative treatment after 24 and 48 hours (P < 0.001). CONCLUSIONS: Age above 70, diabetes, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (> 15,000) suggests refractory disease and should play a central role in the clinical follow-up and decision-making process for elderly patients with acute cholecystitis.

Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury.

BACKGROUND: The recent growth in the volume of civilian blast trauma caused by terrorist bombings warrants special attention to the specific pattern of injury associated with such attacks. OBJECTIVE: To characterize the abdominal injuries inflicted by terrorist-related explosions and to compare the pattern of injury with civilian, penetrating and blunt, abdominal trauma. METHODS: Retrospective analysis of prospectively collected data from 181 patients with abdominal trauma requiring laparotomy, who were admitted to the Hadassah Hospital, Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into 3 groups according to mechanism of injury: terror-related blast injury (n = 21), gunshot wounds (GSW) (n = 73) and blunt trauma (n = 87). RESULTS: Median injury severity score in the blast group was significantly higher compared with GSW and blunt groups (34, 18, and 29, respectively, P < 0.0001). Injury to multiple body regions (> or = 3) occurred in 85.7% of blast group, 28.8% of GSW group, and 59.7% of blunt group (P < 0.001). The pattern of intra-abdominal injury was different between the groups. Bowel injury was found in 71.4% of blast victims, 64.4% of GSW, and 25.3% of blunt group (P < 0.001). Parenchymal injury was found in one third of patients in blast and GSW groups versus 60.9% of patients in blunt group (P = 0.001). Penetrating shrapnel was the cause of bowel injury in all but 1 patient in the blast group (94.4%). CONCLUSIONS: Terrorist attacks generate more severe injuries to more body regions than other types of trauma. Abdominal injury inflicted by terrorist bombings causes a unique pattern of wounds, mainly injury to hollow organs. Shrapnel is the leading cause of abdominal injury following terrorist bombings.

Gastric arterio-venous malformation emerging from splenic artery.

In this case report, we present a patient who suffered from gastrointestinal bleeding. The bleeding source was a gastric arterio-venous malformation emerging from the splenic artery. Attempts to stop the bleeding failed and therapeutic angiography succeeded in occluding the vessel. A search at the literature has not yielded any other case report describing this anatomical anomaly.

[Blunt small bowel injuries--a challenging diagnosis].

Blunt abdominal trauma is a common cause for admission of casualties to emergency departments and trauma units. The most commonly involved organs during blunt abdominal trauma are solid organs such as the spleen and the liver. Small bowel injuries caused by blunt abdominal trauma are relatively rare. The diagnosis of small bowel injuries is frequently delayed. The delay in diagnosis may contribute to relatively high rates of morbidity and even mortality. Physical examination of the patient is suggestive for injury in only half of the patients and further diagnostic modalities are usually needed. In this article we present two patients who were involved in motor vehicle accidents and underwent operations in our medical center because of small bowel injuries. We also present the current medical literature regarding this pathology.

Blunt splenic trauma: predictors for successful non-operative management.

BACKGROUND: Non-operative management of blunt splenic trauma is the preferred option in hemodynamically stable patients. OBJECTIVES: To identify predictors for the successful non-operative management of patients with blunt splenic trauma. METHODS: The study group comprised consecutive patients admitted with the diagnosis of blunt splenic trauma to the Department of Surgery, Hadassah-Hebrew University Medical Center in Jerusalem over a 3 year period. Prospectively recorded were hemodynamic status, computed tomography grade of splenic tear, presence and extent of extra-abdominal injury, number of red blood cell units transfused, and outcome. Hemodynamic instability and the severity of associated injuries were used to determine the need for splenectomy. Hemodynamically stable patients without an indication for laparotomy were admitted to the Intensive Care Unit and monitored. RESULTS: There were 64 adults (45 males, mean age 30.2 years) who met the inclusion criteria. On univariate analysis the 13 patients (20.3%) who underwent immediate splenectomy were more likely to have lower admission systolic blood pressure (P= 0.001), Glasgow Coma Scale < 8 (P= 0.02), and injury to at least three extra-abdominal regions (P= 0.06). Nine of the 52 patients (17.3%) who were successfully treated non-operatively suffered from grade > or = 4 splenic tear. Multivariate analysis identified admission systolic BP (odds ratio 1.04) and associated injury to less than three extra-abdominal regions (OD 8.03) as predictors for the success of non-operative management, while the need for blood transfusion was a strong predictor (OR 66.67) for splenectomy. CONCLUSIONS: Admission systolic blood pressure and limited extra-abdominal injury can be used to identify patients with blunt splenic trauma who do not require splenectomy and can be safely monitored outside an ICU environment.

When a vehicle becomes a weapon: intentional vehicular assaults in Israel.

BACKGROUND: We have recently witnessed an epidemic of intentional vehicular assaults (IVA) aimed at pedestrians. We hypothesized that IVA are associated with a specific injury pattern and severity. METHODS: Retrospective analysis of prospectively acquired data of patients injured following IVA from October 2008 to May 2016 who were admitted to the Hadassah Level I trauma center in Jerusalem, Israel. Comparison of injury parameters and outcome caused by vehicular attacks to non-intentional pedestrian trauma (PT). Measured outcomes included ISS, AIS, injury pattern, ICU and blood requirements, participating teams, length of stay, and mortality. RESULTS: There were 26 patients in the IVA group. Mean age in the IVA group was significantly younger and there were more males compared to the PT group (24.7 ± 13.3 years vs. 48.3 ± 21.3, and 81% vs. 52%, respectively, p < 0.01). Lower extremity (77% of patients), followed by head (58%) and facial (54%) injuries were most commonly injured in the IVA group, and this was significantly different from the pattern of injury in the PT group (54, 35, and 28%, respectively, p < 0.05). Mean ISS and median head AIS were significantly higher in the IVA group compared with the PT group (23.2 ± 12.8 vs. 15.4 ± 13.8, p = 0.012, and 4.5 vs. 3, p = 0.003, respectively). ICU admission and blood requirement were significantly higher in the IVA group (69% vs. 38%, and 50% vs. 19%, p < 0.01). Mortality was significantly higher in the IVA group (4 patients, 15%, vs. 3 patients, 4%, respectively, p = 0.036) and was caused by severe head trauma in all cases. DISCUSSION: The severity of injury and mortality rate following IVA are higher compared with pedestrian injury. The pattern of injury following IVA is significantly different from non-intentional pedestrian trauma. CONCLUSIONS: IVA results in higher mortality than conventional pedestrian trauma secondary to more severe head injury. More hospital resources are required following IVA than following conventional road traffic accidents.

Civilian casualties of terror-related explosions: The impact of vascular trauma on treatment and prognosis.

OBJECTIVES: A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non-terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. RESULTS: Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25-75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals' resources were used-trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). CONCLUSIONS: Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital's resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Can external signs of trauma guide management?: Lessons learned from suicide bombing attacks in Israel.

BACKGROUND: Following a suicide bombing attack, scores of victims suffering from a combination of blast injury, penetrating injury, and burns are brought to local hospitals. OBJECTIVE: To identify external signs of trauma that would assist medical crews in recognizing blast lung injury (BLI) and effectively triaging salvageable and nonsalvageable victims. DESIGN: Retrospective analysis of all 15 suicide bombing attacks that occurred in Israel from April 1994 to August 1997. SETTING: National survey. PATIENTS: One hundred fifty-three victims died and 798 were injured as a result of 15 attacks. Medical records were reviewed for external signs of trauma, such as burns and penetrating injuries, and the presence of BLI. Main Outcome Measure The odds ratio for BLI and death. RESULTS: Three settings were targeted: buses, semiconfined spaces, and open spaces. Sixty survivors (7.5%) suffered from BLI, which was more common in buses (37 of 260) than semiconfined spaces (14 of 279) and open spaces (9 of 259) (P<.001). Victims with BLI were more likely to suffer from penetrating injury to the head or torso, burns covering more than 10% of the body surface area, and skull fractures (odds ratios, 4, 11.6, and 55.8, respectively; P<.001). Victims who died at the scene were more likely to suffer from burns, open fractures, and amputations in comparison with survivors (odds ratios, 6.5, 18.6, and 50.1, respectively; P<.001). CONCLUSIONS: Following a suicide bombing attack, external signs of trauma should be used to triage victims to the appropriate level of care both at the scene and in the hospital. Triage of salvageable and nonsalvageable victims should take into account the presence of amputations, burns, and open fractures.

Perioperative outcomes of delayed laparoscopic cholecystectomy for acute calculous cholecystitis with and without percutaneous cholecystostomy.

INTRODUCTION: The role of percutaneous cholecystostomy (PC) in the management of patients with acute calculous cholecystitis (ACC) remains controversial. The aim of this study is to report operative outcomes in a large cohort of patients undergoing PC before their delayed laparoscopic cholecystectomy (DLC). METHODS: All patients who underwent DLC because of ACC between 2003 and 2012 were included. Outcomes of patients with and without previous PC were compared. RESULTS: Of 639 patients who underwent DLC because of ACC at our institution during a 10-year time interval beginning 2003, 163 (25.5%) patients had PC before their DLC. Patients who underwent PC were older (64 ± 1 years vs 48 ± 0.8 years, P < .001) and had more comorbid conditions (P < .001). Accumulated duration of stay was longer in the PC group (16.2 ± 0.4 days vs 9.7 ± 0.1 days, P < .001). Rate of conversion to open procedure was greater in the PC group (11% vs 4%, P = .001) and operative time was longer (142 ± 4 minutes vs 107 ± 4 minutes, P < .001). Patients in the PC group had a greater rate of biliary-related complications (10% vs 4%, P = .003) and surgical-site infections; both superficial (5% vs 1%, P = .004) and deep (7% vs 3%, P = .04). On multivariable analysis PC was an independent risk factor for conversion to open cholecystectomy (odds ratio 2.67 95% CI 1.18-6.72) as well as to biliary-related complications (odds ratio 4.85 95% CI 1.57-14.92). CONCLUSION: DLC for ACC in patients with previous PC is associated with longer duration of stay, more readmissions, and, most importantly, greater conversion rate, biliary related complications, and surgical-site infections.

Longitudinal gastrectomy as a treatment for the high-risk super-obese patient.

BACKGROUND: Bariatric surgery in patients with significant co-morbid conditions is associated with increased perioperative risk. METHODS: From 1995-2001, 795 patients were operated upon at our institution for the diagnosis of morbid obesity. Of these, 671 (84.4%) had the duodenal switch (DS) procedure. Longitudinal gastrectomy (LG) entails a greater curvature linear gastrectomy creating a gastric tube with a volume of 100 ml along the lesser curvature of the stomach. This procedure was performed for 21 patients (median age 50.5, median BMI 56). 9 patients were offered LG preoperatively because of their known high perioperative risks. 12 patients were initially planned for DS, but the procedure was limited to LG alone because of either unexpected intraoperative findings (n=9) or intraoperative hemodynamic instability (n=3). 5 patients developed complications, and there were no deaths. RESULTS: 19 out of 21 patients were available for a median follow-up of 17.5 months (6.25-20.25). Median weight loss and median %EWL at 12 months were 44.5 kg and 45.1%, respectively. Estimated daily dietary volume at 1 year was 35% of preoperative values. Of 10 patients followed for >or= 1 year, 4 of 10 achieved more than 50% EWL and 8 patients were taking less or were completely off medications for diabetes, hypertension and congestive heart failure. Weight loss plateaued at 1 year for the majority of patients. CONCLUSIONS: LG is a safe and effective option for high-risk morbidly obese patients. Weight reduction is accomplished by limitation of caloric intake. LG can be offered to high-risk morbidly obese patients as an interim procedure to help decrease perioperative risk before DS.

Achalasia in the context of morbid obesity: a rare but important association.

BACKGROUND: The simultaneous occurrence of achalasia and morbid obesity is rare. Nevertheless, the surgical therapy of morbid obesity may be harmful, if undiagnosed achalasia were left untreated. We report the clinical presentation and response to treatment of achalasia in the context of morbid obesity. METHODS: From 1998 to 2002, 638 patients underwent surgery for morbid obesity. Preoperative upper gastrointestinal radiography was performed in all patients. Three patients had manometric confirmation of achalasia. The characteristic symptoms were recurrent episodes of regurgitation, chronic cough and aspiration. No patient reported dysphagia or recent weight loss. RESULTS: All patients had a duodenal switch procedure and in two a concurrent Heller myotomy was added. The other patient required a Heller myotomy after a duodenal switch had been performed, because the motility study was initially misinterpreted. All patients reported gradual resolution of presenting symptoms after myotomy. CONCLUSIONS: A careful symptomatic history focusing on aspiration, regurgitation and cough may identify the unusual combination of achalasia and morbid obesity. Treatment of morbid obesity alone may lead to progression of pulmonary symptoms.