Subcutaneous placement of lap band port without fascial fixation provides safe and durable access.

BACKGROUND: Laparoscopic adjustable gastric band access port has been routinely sutured to the anterior fascia of the abdominal wall using nonabsorbable sutures. We present our technique demonstrating that nonfascial fixation with using a mesh allows for a safe and durable placement of the port in the superficial subcutaneous tissue. METHODS: Retrospective chart review included 102 consecutive patients who had Lap band surgery performed by single surgeon (EA) from June 2011 until April 2013. The port was sutured to a piece of polypropylene mesh and tunneled in the subcutaneous tissue away from the incision. Patients' demographics were analyzed as well as the following parameters: OR time for port placement, follow-up, port complications requiring revision, difficult access facilitated by fluoroscopy imaging, port infection, and skin erosion. RESULTS: The study included 102 consecutive patients (23 males and 79 females), mean age was 49 years old, mean weight was 284.7 lb, mean height was 66.2 in., and mean body mass index (BMI) was 46.3 kg/m(2). The average operative time for port placement was 4 min, mean follow-up was 12 months, port complications occurred in 2 % of the patients while fluoroscopy for difficult port access was required in 3 %. No cases of port infections or skin erosions occurred. CONCLUSIONS: Superficial subcutaneous placement of Lap Band Port using mesh fixation without anchoring the port to the fascia provides safe and durable access. Deep incisions to secure the port directly to the fascia might not be necessary.

Catastrophic bleeding from a marginal ulcer after gastric bypass.

Marginal ulceration at the gastrojejunal anastomosis is a common complication following Roux-Y gastric bypass (RYGB). Hemodynamically significant hemorrhagic marginal ulcers are usually treated either endoscopically or surgically. We describe a unique case of life-threatening hemorrhagic marginal ulcer eroding into the main splenic artery. This condition was initially managed with angiographic embolization, followed by surgical intervention.

Bariatric surgery evolution from the malabsorptive to the hormonal era.

While bariatric procedures continued to evolve and develop since the 1950s, their classification has not matched this evolution. The procedures are commonly classified into restrictive, malabsorptive, or combined. In this day and age, we recognize different mechanisms of action of the bariatric procedures. This article aims to review and update the old classifications based on our current understanding of the hormonal aspects of the various bariatric procedures and the role of gut hormones in weight loss and treatment of the associated metabolic comorbidities. The article suggests the need for a new classification of the bariatric procedures, based on the mechanism of action, involving the hormonal aspects of the procedure.

Sutureless laparoscopic ventral hernia repair in obese patients.

BACKGROUND AND OBJECTIVE: Transfascial sutures (TFS) are a standard component of laparoscopic ventral herniorrhaphy (LVHR) that contribute to the durability of repair, but also pain and, resultantly, hospital stay. We sought to examine LVHR without TFS in obese patients with small abdominal wall hernias. METHODS: Between September 2002 and December 2007, 174 patients underwent LVHR at Yale-New Haven Hospital. Patients with BMI >30kg/m(2) and small primary abdominal wall hernias were eligible for repair without TFS. Correlation between BMI, defect surface area, operative time, and postoperative stay was assessed. RESULTS: Fourteen patients underwent LVHR with no TFS, 2 with normal BMI and recurrent hernia after open repair and 12 with BMI >30 kg/m(2) and primary small hernia. Mean age was 38.8 years. The average defect size was 5.3cm(2); mean operative time (OT) was 42 minutes. Eleven patients (92%) were discharged home the day of surgery. No infectious or bleeding complications occurred. One patient required chronic pain management, and 8 patients (67%) developed seromas that resorbed spontaneously. There was no hernia recurrence at 7-month follow-up. CONCLUSION: LVHR is feasible without TFS provided the hernia defect is small. Surgery can be performed on an outpatient basis in obese individuals with minimal postoperative morbidity.

Survey of the effective exercise habits of the formerly obese.

BACKGROUND AND OBJECTIVE: Patients must subscribe to behavioral and lifestyle modifications for continued success after weight loss surgery (WLS). Few data exist about the ideal type, duration, and intensity of exercise for WLS patients. After surgery, should we mandate that patients exercise like a young, lean individual does? To reconcile this, we compared the exercise habits of successful bariatric surgery patients with physically fit controls. METHODS: One hundred individuals were enrolled. The operative group (OG) included 50 laparoscopic Roux-Y gastric bypass patients (LRYGB) who achieved excess weight loss of at least 80% one year after the surgery. The control group (CG) included 50 individuals of normal BMI who exercised regularly and did not undergo LRYGB. The exercise habits were compared using Fisher's exact and Mantel-Haenszel chi square tests. RESULTS: The 2 groups had equivalent BMIs (24.7 vs. 23.4 kg/m(2)). The OG was older (39.5 years) than the CG (26.2 years). There was a statistically significant difference between the groups regarding cardiovascular exercise, 80% walking (OG) vs. 60% running (CG). OG patients exercised longer and with similar frequency as CG did. A high proportion of CG lifted weights (86%) vs. OG (44%). Sixty percent of CG performed recreational sports compared with 34% of OG. CONCLUSION: Regular exercise is of utmost importance in maximizing and maintaining weight loss after WLS. Although patients who undergo WLS are older than the typical exercise enthusiast, they can achieve excellent weight loss and sustain a normal BMI with regular exercise habits that are quite distinct from younger individuals whose bodies were never undermined by obesity.

Superior mesenteric artery aneurysm: an uncommon disease with potentially serious complications.

Superior mesenteric artery aneurysms (SMAAs) are visceral arterial aneurysms that can result from a variety of conditions. About half of SMAAs are mycotic and occur subsequent to infective endocarditis. The clinical presentation of SMAA is nonspecific, and some patients may be asymptomatic while others may report mild to severe abdominal pain. Herein, we present a case of a 53-year-old man who presented to the emergency department with abdominal pain 5 months after receiving medical treatment for infective endocarditis. CT scan demonstrated an aneurysm in the superior mesenteric artery and a splenic infarct. The patient underwent surgical excision with an uneventful recovery. Although rare, SMAAs are associated with a high risk of death secondary to rupture. They are difficult to detect through physical examination and the history is usually nonspecific. In this report we discuss the etiology of SMAA, diagnostic work-up and treatment options aiming for early diagnosis and management of this potentially fatal condition.

The role of haptic feedback in laparoscopic simulation training.

INTRODUCTION: Laparoscopic virtual reality simulators are becoming a ubiquitous tool in resident training and assessment. These devices provide the operator with various levels of realism, including haptic (or force) feedback. However, this feature adds significantly to the cost of the devices, and limited data exist assessing the value of haptics in skill acquisition and development. Utilizing the Laparoscopy VR (Immersion Medical, Gaithersburg, MD), we hypothesized that the incorporation of force feedback in the simulated operative environment would allow superior trainee performance compared with performance of the same basic skills tasks in a non-haptic model. METHODS: Ten medical students with minimal laparoscopic experience and similar baseline skill levels as proven by performance of two fundamentals of laparoscopic surgery (FLS) tasks (peg transfer and cutting drills) voluntarily participated in the study. Each performed two tasks, analogous to the FLS drills, on the Laparoscopy VR at 3 levels of difficulty, based on the established settings of the manufacturer. After achieving familiarity with the device and tasks, the students completed the drills both with and without force feedback. Data on completion time, instrument path length, right and left hand errors, and grasping tension were analyzed. The scores in the haptic-enhanced simulation environment were compared with the scores in the non-haptic model and analyzed utilizing Student's t-test. RESULTS: The peg transfer drill showed no difference in performance between the haptic and non-haptic simulations for all metrics at all three levels of difficulty. For the more complex cutting exercise, the time to complete the tasks was significantly shorter when force feedback was provided, at all levels of difficulty (158+/-56 versus 187+/-51 s, 176+/-49 versus 222+/-68 s, and 275+/-76 versus 422+/-220 s, at levels 1, 2, and 3, respectively, P<0.05). Data on instrument path length, grasping tension, and errors showed a trend toward a benefit from haptics at all difficulty levels, but this difference did not achieve statistical significance. CONCLUSIONS: In the more advanced tasks, haptics allowed superior precision, resulting in faster completion of tasks and a trend toward fewer technical errors. In the more basic tasks, haptic-enhanced simulation did not demonstrate an appreciable performance improvement among our trainees. These data suggest that the additional expense of haptic-enhanced laparoscopic simulators may be justified for advanced skill development in surgical trainees as simulator technology continues to improve.

Socioeconomic predictors of weight loss after laparoscopic Roux-Y gastric bypass.

INTRODUCTION: Successful weight loss after laparoscopic Roux-Y gastric bypass (LRYGB) hinges on many elements including neurohormonal, anatomical, and postoperative behavioral changes. To date, the effects of socioeconomic factors have been inadequately studied. We examine several components of socioeconomic status and its relationship to weight loss after LRYGB. METHODS: Between August 2002 and July 2006, 405 LRYGB were performed by a single surgeon. Patient demographics were entered into a longitudinal, prospective database. At 1-year follow-up, 309 patients were available for analysis. Regional median household income (RMAHI) and primary insurance carrier were used as surrogates for preoperative socioeconomic status. Analysis of covariance (ANCOVA) test was used for statistical analysis. According to RMAHI, we divided the patients into three groups: US $20,001-40,000 (group A, n = 67), US $40,001-60,000 (group B, n = 153), and more than US $60,000 (group C, n = 89). Initial body mass index (BMI) was 52.76 +/- 1.01, 51.28 +/- 0.67, and 48.87 +/- 0.94 kg/m2, respectively. Additionally, patients were divided according to private insurance or state-based insurance. A total of 274 patients had private insurance, with an initial mean BMI of 50.6 kg/m2, and 35 patients had state-based insurance, with an initial BMI of 53.0 kg/m2. RESULTS: After 1 year, weight loss in groups A, B and C was 110.6 +/- 4.3, 110.0 +/- 2.5, and 103.9 +/- 3.6 lb with BMI decrease of 17.7 +/- 0.6, 17.7 +/- 0.4, and 16.9 +/- 0.6 kg/m2, respectively. Weight loss in the private insurance group was 49.2 +/- 0.9 kg compared with 50.2 +/- 2.3 kg in the state-based group with BMI decrease of 17.4 +/- 0.3 and 18.4 +/- 0.8 kg/m2, respectively. There were no statistical significances in the effect of socioeconomic status, median household income, and insurance carrier on postoperative weight loss. CONCLUSION: With appropriate patient selection, the socioeconomic status of patients undergoing LRYGB does not affect postoperative weight loss.

The paradox of the pouch: prompt emptying predicts improved weight loss after laparoscopic Roux-Y gastric bypass.

INTRODUCTION: The utility of routine upper gastrointestinal (UGI) evaluations after laparoscopic Roux-Y gastric bypass (LRYGB) has yet to be determined, primarily being used to rule out a gastrojejunal leak. Additional information can be assessed with these studies, including the rate of contrast emptying from the pouch; some patients show no or very slow emptying while others show a faster rate of emptying. No or slow emptying is likely due to anastomotic edema and/or a small initial stomal diameter. The aim of this study is to ascertain whether initial pouch emptying (or lack thereof) predicts postoperative weight loss. METHODS: Between August 2002 and July 2006, 405 LRYGB were performed by a single surgeon using a linear stapler technique. Patient demographics were entered into a longitudinal, prospective database. All patients had an UGI study on postoperative day 1. At 1-year follow-up, 304 patients were available for analysis. The patients were divided into two groups: group A, 188 patients with normal gastric emptying, and group B, 116 patients with very slow or no emptying of contrast. Analysis of covariance (ANCOVA) was used to compare weight loss between the two groups. The following covariates were considered in all analyses: age, sex, length of stay, and operative time. RESULTS: There was a statistically significant difference in weight loss between the two gastric emptying groups adjusting for age, sex, and operative time (p=0.007). Subjects with prompt gastric emptying (group A) showed more weight loss (50.6 kg versus 47.3 kg) and greater body mass index (BMI) loss (mean loss of 18.1 versus mean loss of 16.6 kg/m(2)) when compared with group B patients with slow or no emptying of the gastric pouch. CONCLUSIONS: Many factors (psychosocial, behavioral, hormonal, and anatomical) influence weight loss after LRYGB. Although we are uncertain of the mechanism, patients with normal initial pouch emptying tend to lose more weight than patients who initially exhibit slow or no emptying of the gastric pouch.

Deciphering the sleeve: technique, indications, efficacy, and safety of sleeve gastrectomy.

Some institutions perform sleeve gastrectomy (SG) as the initial operation for high-risk, high body mass index patients planning a definitive weight loss operation in 12-18 months. Other institutions consider SG a viable alternative to other bariatric operations. SG is frequently debated among the bariatric surgeons. Many questions remain about the current state of SG. Should it be performed as a definitive weight loss procedure or as a bridge for another bariatric procedure? Is there a specific BMI at which point SG should be encouraged? Is the weight loss comparable to other bariatric procedures? Is there a higher risk of gastric leak? What is the appropriate sleeve size? What are the hormonal benefits? Does SG predispose to gastroesophageal reflux disease? What is the mechanism of weight loss? Are long-term results available? And what are the complications? We conducted an extensive literature review aiming to resolve these commonly asked questions.