Revisional bariatric surgery for unsuccessful weight loss and complications.

BACKGROUND: There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery. METHODS: We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes. RESULTS: From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3%) of these cases were coded as revisional procedures. The mean age at revision was 49.1 ± 11.3 and the mean BMI was 44.0 ± 13.7 kg/m2. Revisional surgery was performed laparoscopically in 121 patients (78.6%). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n = 106) and patients with complications of their primary procedures (group B, n = 48). In group A, 74.5% of the patients were revised to a bypass procedure and 25.5% to a restrictive procedure. Mean excess weight loss was 53.7 ± 29.3% after revision of primary restrictive procedures and 37.6 ± 35.1% after revision of bypass procedures at >1-year follow-up (p < 0.05). In group B, the complications prompting revision were effectively treated by revisional surgery. CONCLUSIONS: Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.

A rare case presentation of a symptomatic omphalomesenteric cyst in an adult, 24-year-old patient, treated with laparoscopic resection.

A persistent omphalomesenteric duct remnant is a rare finding, which typically presents in the pediatric population. Most commonly, it is encountered in the form of a Meckel's diverticulum. In rare instances, omphalomesenteric cysts have been reported in the pediatric population. We present a case of a symptomatic omphalomesenteric cyst in an adult male and our management of this entity.

Obesity does not adversely affect outcomes after laparoscopic splenectomy.

BACKGROUND: Obesity is still considered a relative contraindication to laparoscopic splenectomy (LS). METHODS: All patients undergoing LS at our institution were classified as obese or nonobese (group A, body mass index [BMI] >30; group B, BMI <30). Primary end points included conversion rate, operative complications, length of stay, operative time, and estimated blood loss (EBL). RESULTS: Three hundred seventy patients who underwent LS were included. Baseline characteristics were similar in groups A (n = 127; mean BMI, 36.2 ± 6.9 kg/m²) and B (n = 243; mean BMI, 24.6 ± 2.9 kg/m²). Conversion rates and overall morbidity were similar in both groups (9% vs 11% for conversion to open procedures, P = .621; 16% vs 16% for morbidity rates, P = .940). Length of hospital stay and EBL were also comparable (P = .643 and P = .544, respectively). Mean operative time was significantly increased in the obese group on multivariate analysis (170 vs 151 minutes, P = .021). CONCLUSIONS: Obesity does not adversely affect outcomes after LS. The laparoscopic approach is the optimal technique for splenectomy regardless of the patient's weight.

Dramatic response of a gastrointestinal stromal tumor to neadjuvant imatinib therapy.

Gastrointestinal stromal tumors (GISTs) are the most common sarcoma of the alimentary tract and are believed to derive from the interstitial Cell of Cajal. Imatinib mesylate (Gleevec; Novartis, Basel, Switzerland) has revolutionized the treatment of GISTs and is generally used in the metastatic and adjuvant settings. We report the case of a 61-year old man who was treated with neoadjuvant imatinib for a massive gastric GIST with the hope of avoiding a potential multi-visceral resection.

Measuring the "fifth vital sign" in cataract surgery patients--is it necessary?

As an ophthalmic nurse, you may wonder why it is so important to assess and manage the pain, or "fifth vital sign" of cataract surgery patients. How much pain could a patient experience as a result of a relatively short procedure? In January 2004, while reviewing the pain levels of 135 outpatient surgery patients undergoing cataract surgery, 21% of the patients reported pain. Twelve percent (12%) experienced mild pain and 9% experienced moderate to severe pain. Pain relief was recorded in 38% of cases. It was noted that there was no pain reassessment recorded by nurses in 62% of cases, demonstrating a deficit in pain assessment and documentation. At our institution, the Wilmer Eye Institute at Johns Hopkins Hospital, there is a pain assessment and management policy that requires a postoperative pain goal be identified prior to any surgical procedure. Hospital guidelines should be followed for documentation of pain in the outpatient setting. To improve the quality of pain assessment and documentation, and to meet the hospital compliance rate of 85%, an audit was performed on 60 outpatient cataract surgery charts over a one-month period. An initial compliance rate of 83% was established. After staff education and changes to the critical pathway, a re-audit demonstrated an increase to 95% in pain assessment and documentation.