Surgical implications of a left-sided gallbladder.

BACKGROUND: A left-sided gallbladder in a normally positioned liver is considered to be a very uncommon anomaly. Laparoscopic cholecystectomy can be performed safely, but bile duct injury is not unusual. It is associated with anomalous intrahepatic portal and biliary systems which impacts any form of partial hepatectomy. METHODS: We performed a retrospective review of patients with left-sided gallbladder who were managed by the hepatobiliary surgeons at our institution since 1996. RESULTS: Nineteen patients with left-sided gallbladder underwent a hepatobiliary procedure. Of the 13 patients with gallstones, only 1 was diagnosed before cholecystectomy. Nine operations were completed laparoscopically, whereas 4 required an open procedure. Two patients were referred with bile duct injuries. There was 1 liver resection for a colorectal metastasis. Left-sided gallbladders in 3 deceased organ donors resulted in major implications in the performance of liver transplantation. CONCLUSIONS: Left-sided gallbladders are probably more common than generally believed but are rarely diagnosed before cholecystectomy. Associated bile duct injury appears to be not infrequent. Because of the aberrant vasculobiliary anatomy, any form of liver resection requires careful planning.

Prevention of pelvic sepsis in major open pelviperineal injury.

Compound pelvic fractures are deemed to be one of the most severe orthopaedic injuries with an extremely high morbidity and mortality. After the initial resuscitation phase the prevention of pelvic sepsis is one of the main treatment goals for patients with an open pelvic fracture. If there is a suspicion of a rectal injury or if the wounds are in the perineal area, The Princess Alexandra Hospital's management plan includes early faecal diversion combined with vigorous soft tissue debridement, VAC(®) therapy and (if indicated) external fixation of the pelvic fracture. We present our flowchart for the treatment of trauma patients with compound pelvic fractures illustrated by a case report describing a 32 year old patient who sustained an open pelvic ring injury in a workplace accident. The aim of this paper is to underline the importance of a safe, straightforward approach to compound pelvic fractures.

A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch.

OBJECTIVE: To compare biliopancreatic diversion (BPD) without duodenal switch (DS) and with duodenal switch (BPDDS). BACKGROUND: A reduction of 70% of excess body weight can be achieved after BPD, but there is a risk of malnutrition and diarrhea. This risk may be reduced by pyloric preservation with BPDDS. METHODS: BPD was performed until 1999, when BPDDS was introduced, both with a common channel of 50 cm. At their latest clinic visit, patients filled in a questionnaire regarding weight loss, dietary history, gastrointestinal symptoms, obesity-related comorbidity, and medication including dietary supplements and underwent a serum nutritional screen. RESULTS: BPD was performed in 73 patients and BPDDS in 61 patients, with a median preoperative body mass index (BMI) of 44.8 kg/m and a median follow-up of 28 months. There were no significant differences between BPD and BPDDS with regards to age, sex, BMI, or morbidity. Median excess weight loss and BMI at 12, 24, and 36 months was 64.1, 71.0, and 72.1% and 33.1, 31.5, and 31.5 kg/m, respectively; there were no significant differences between BPD and BPDDS. There were no significant differences between BPD and BPDDS with regards to meal size, fat score, nausea, vomiting, diarrhea, or nutritional parameters. However, 18% of patients were hypoalbuminemic, 32% anemic, 25% hypocalcemic, and almost half had low vitamin A, D, and K levels, despite more than 80% taking vitamin supplementation. CONCLUSION: DS does not improve weight loss or lessen the gastrointestinal or nutritional side effects of BPD.

A comparison of laparoscopic adjustable gastric banding and biliopancreatic diversion in superobesity.

BACKGROUND: Controversy exists regarding the best surgical treatment for superobesity (BMI >50 kg/m(2)), and a comparison of the 2 most commonly performed procedures in Europe, namely biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB), has not yet been reported. METHODS: BPD has been performed in 134 morbidly obese patients since 1996, and as the primary bariatric procedure in 23 superobese patients. 23 sex-matched patients who most closely resembled the age and BMI of the 23 BPD patients were chosen from 1319 patients who had undergone LAGB since 1996. These groups were compared using appropriate statistical tests. RESULTS: BPD was performed laparoscopically in 12 patients. Median excess weight loss at 24 months was 64.4% following BPD and 48.4% following LAGB. Hospital stay and complication rate were significantly greater with BPD, although the majority of complications were related to the laparotomy wound in patients undergoing open BPD. Rate of resolution of obstructive sleep apnea, hypertension and diabetes mellitus following LAGB was similar to BPD. CONCLUSION: BPD results in significantly greater weight loss than LAGB in superobese patients, but is associated with a longer hospital stay and a higher complication rate in patients undergoing open BPD.

Calcium and vitamin D depletion and elevated parathyroid hormone following biliopancreatic diversion.

BACKGROUND: Biliopancreatic diversion (BPD) is associated with a 70% excess weight loss (EWL) at 10 years, but there are concerns regarding long-term nutritional sequelae. Metabolic bone disease has been documented following Roux-en-Y gastric bypass. METHODS: Patients who underwent a BPD from 1998 to 2001 were studied. A questionnaire was designed to review BPD patients and collect information on weight loss, frequency of gastrointestinal disturbances and compliance with multivitamin recommendations. The review included a blood test for vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium. RESULTS: Of the 82 patients who underwent BPD during this period, the median %EWL at 36 months was 73.0%. 75.6% suffered diarrhea. At median follow-up of 32 months (18-50), 25.9% of patients were hypocalcemic, 50% had low vitamin D, 23.8% had elevated ALP, and 63.1% had elevated PTH, despite 82.9% taking multivitamins. CONCLUSION: BPD results in significant weight loss. However, 1 in 4 patients are hypocalcemic, and 1 in 2 have a low vitamin D, despite multivitamin supplementation. BPD patients require routine calcium and vitamin D supplementation for life. Long-term sequelae from these abnormal serum levels are not known.