Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia: A Technical Report.

Introduction: Occult diaphragmatic hernias after trauma are relatively rare and may present months to years after the traumatic event. Clinical presentations range from asymptomatic incidental findings on imaging to life-threatening incarceration of abdominal visceral organs. This study presents a case of a patient with a symptomatic diaphragmatic hernia secondary to a trauma >30 years prior. A literature review of this defect was performed examining the pathophysiology, presentation, and operative considerations. Case Presentation: A 58-year-old male with a history of multiple traumatic motor vehicle accidents 30 years prior presented with abdominal pain and obstructive symptoms. Axial imaging demonstrated a right-sided diaphragmatic hernia defect containing small intestine, colon, and omentum. He ultimately underwent a transabdominal laparoscopic repair of the defect with mesh buttressing. Postoperative the patient recovered well and was discharged without complications. Conclusion: Limited data outside of case reports exist for surgical management of occult diaphragmatic hernias secondary to trauma. Reported management options include open and minimally invasive thoracic as well as open and minimally invasive abdominal approaches; each with advantages and disadvantages. Depending on the defect size, both primary repair and repair with mesh reinforcement are appropriate options. More data comparing the approach and repair technique are needed to determine the best technique.

Effects of Liver Pathology on Sleeve Gastrectomy Outcomes.

Introduction: Sleeve gastrectomy engenders weight loss and improves comorbidities at 1 year postoperatively. A relationship has not been established between liver pathology and diabetic outcomes and weight loss following a sleeve gastrectomy. This study evaluates the association between liver pathology and both diabetic remission and weight loss in morbidly obese veterans. Methods: A prospective database of all patients undergoing sleeve gastrectomy with simultaneous liver biopsy at a Veterans Affairs Medical Center was analyzed from 2018 through 2020. The database included patient demographics, liver biopsy pathology, laboratory values, and antihyperglycemic medications. Patient outcomes at 12 months postoperatively were analyzed specifically for diabetic resolution and weight loss. Chi-square test and Fisher's exact test were used for categorical comparisons, and one-way analysis of variance test and two-tailed t-test were used for continuous variable comparisons. Multivariate linear regression models were created to assess the association between liver pathology and changes in body mass index (BMI) and diabetic status. A two-sided P-value of 0.05 indicated significance. Results: Of the 77 patients included in the study, 70.1% of patients achieved diabetic remission at 12 months. After condensing steatosis and fibrosis scores into low- and high-grade categories, patients with no hepatic disease had significantly lower BMI at 12 months postoperatively than patients with low- or high-grade hepatic disease (29.2 ± 3.6 kg/m2 versus 35.1 ± 4.0 kg/m2 versus 34.5 ± 3.7 kg/m2, respectively, P = .009). On multivariate linear regression model, low-grade overall hepatic disease (ß = 3.1 ± 1.5; P = .043) and preoperative oral glycemic medications (ß = 2.4 ± 1.0; P = .026) were associated with a significantly increased 12-month BMI. Also, Black or African American race compared with White race was associated with a significant decrease in postoperative BMI (ß = -1.9 ± 0.8; P = .023). Conclusions: Regardless of preexisting liver disease, most diabetic patients who undergo sleeve gastrectomy experience diabetic remission at 12 months postoperatively. Additionally, patients with no underlying liver disease lose more weight than those with low- or high-grade liver disease.

Laparoscopic versus single-incision cholecystectomy.

BACKGROUND: Although recent reports demonstrate large series of single-incision cholecystectomies, few articles compare single-incision data with traditional laparoscopic cholecystectomy (LC) data. This article compares a large series of single-incision cholecystectomies to a series of traditional LCs performed at an urban tertiary-care center. METHODS: A consecutive series of single-incision cholecystectomies was performed from August 2008 to March 2010. All cholecystectomies were attempted through a single incision on an intent-to-treat basis. Patient demographics, including height, weight, body mass index (BMI), pathologic diagnosis, ASA classification, operative time, complications, narcotic use, and length of stay (LOS), were recorded. Data for a matched cohort of patients undergoing a traditional four-port LC were gathered over a similar time period. Data were compared using a t test with a P<0.05 for significance. RESULTS: Single-incision cholecystectomy was successful in 81 (76%) of 107 patients. The 26 (24%) converted cases showed a higher BMI (33.0±8.7 vs. 28.4±6.4 kg/m2, P<0.05) and longer operative times (98.3±33 vs. 76.1±23 min, P<0.003). Postoperatively, the converted patients had a longer LOS compared to that of the single-incision group (1.6±1.0 vs. 1.1±0.4 days, P=0.02). Overall, the single-incision group had longer operative times compared to the four-port LC group (81.5±28 vs. 69.1±21 min, P<0.004). However, after the tenth single-incision case, there was no difference in operative times. From a narcotic standpoint, the successful single-incision patients used significantly less narcotic versus the traditional LC group (20±22.7 vs. 32.3±31.2 mg, P=0.02). CONCLUSIONS: The data suggests that individuals with a BMI over 33 may not be candidates for single-incision cholecystectomy. Those patients that undergo a successful single-incision laparoscopic cholecystectomy require fewer narcotics postoperatively and have a shorter LOS. Although this data is intriguing, the overall utility of single-incision procedures requires more analysis and potentially randomized trials.

Analysis of poor outcomes after laparoscopic adjustable gastric banding.

BACKGROUND: Recent studies document excess weight loss (EWL) of more than 50% with the laparoscopic adjustable gastric band (LGB). This study reviews the LGB experience at an urban academic center in terms of complications, reoperative rates, and comorbidities. METHODS: In this study, 144 consecutive patients undergoing LGB were prospectively reviewed. Data were collected including weight, body mass index (BMI), excess weight loss (EWL), comorbidities, and complications. Demographics were analyzed using a t-test. Linear regression was used to analyze the relationship of BMI, race, and age to EWL at 12 months. RESULTS: The study participants were 130 women with a mean age of 43 ± 11 years, a mean weight of 127.1 kg ± 20.5 kg, and a mean BMI of 45.6 ± 6.1. The mean follow-up period was 16 months. The mean EWL was 20% ± 14% at 6 months (n = 118), 26% ± 16% at 12 months (n = 106), 30% ± 20% at 18 months (n = 68), and 34% ± 23% at 24 months (n = 43). Patients with a BMI higher than 50 kg/m(2) had a lower EWL at 12 months than patients with a BMI lower than 50 kg/m(2) (P = 0.00005). The mean EWL at 12 months was significantly less for African Americans than for Caucasians (P = 0.0046; 95% confidence interval [CI] 3-15%). Patients older than 50 years had a lower EWL, but the difference was not statistically significant (P = 0.07). Complete and partial resolution of comorbidities occurred for 10% and 4% of the patients, respectively. Removal of the band with revision to a sleeve gastrectomy for inadequate EWL was required for 14 patients (11.5%). Complications occurred for 8% of the patients (n = 15) including port flipping, stoma obstruction, tube disconnection, port infections, dysphagia, and band slippage. Overall, 16.7% of the patients (n = 24) required reoperation. CONCLUSION: After LGB, a majority of the patients failed to achieve a 50% EWL, and 16.7% required reoperation. Laparoscopic adjustable gastric banding may not be the optimal bariatric procedure for patients older than 50 years, patients with a BMI higher than 50 kg/m(2), or African Americans.

Surgery in the Horn of Africa: a 1-year experience of an American-sponsored surgical residency in Eritrea.

OBJECTIVE: To describe the 1-year experience of a unique postgraduate medical education program set in Eritrea, a recently war-torn country. DESIGN: The Partnership for Eritrea, a cooperative between The George Washington University Medical Center, Physicians for Peace, and the Eritrean Ministry of Health, formed a surgical residency program, launched January 2, 2008, in Asmara, Eritrea, to train native Eritrean surgeons. No prior residency program (to our knowledge) had existed in Eritrea. SETTING: Eritrea, a country in the Horn of Africa. PATIENTS: Five Eritrean physicians participated in the surgical residency. MAIN OUTCOME MEASURES: The number of operations performed, length of stay, antibiotic use, and intravenous fluid use. RESULTS: The number of operations increased and resource use decreased because of improved and standardized clinical management. CONCLUSIONS: The Partnership for Eritrea established a general surgical residency program that improved clinical care in a resource-poor country that previously had lacked postgraduate training. The program experience suggests a model that can be reproduced in other developing countries.

Laparoscopy for stage IV melanoma in two organs.

Metastatic melanoma remains a disease associated with poor outcomes. Traditionally, surgical intervention plays a minimal role in its treatment. However, more recent studies document that complete surgical resection of distant metastases is associated with 5-year survival rates of 15% to 30%. These rates are greater than that reported for single-agent or combination chemotherapy, biologic agents or immunotherapy. This case report outlines a unique presentation of stage IV melanoma within the gastrointestinal tract located in 2 different organs. On the basis of the patient's clinical findings, laparoscopic surgery was performed for palliation of intestinal obstruction and bleeding. This approach resulted in less postoperative pain, earlier mobilization, and a faster return to daily activities. To our knowledge, this case details the only known account that uses a laparoscopic approach to palliate stage IV melanoma at 2 synchronous sites; the stomach and small bowel. The literature regarding the treatment of metastatic melanoma is also briefly reviewed.

Laparoscopic resection of a retroperitoneal cystic lymphangioma in an adult.

Cystic lymphangiomas are rare, benign anomalies of the lymphatic system. More than 95% of cystic lymphangiomas occur in the head, neck, and axilla with only 1% in the retroperitoneum. Most of these cases are diagnosed by the second year of life with only a handful of adult cases. Once a symptomatic cystic lesion of the abdomen or retroperitoneum is diagnosed, treatment usually consists of surgical excision. Traditionally, surgery requires a laparotomy. This paper describes a patient with a retroperitoneal cyst who underwent a successful laparoscopic resection. The etiology and management of adult retroperitoneal cysts are reviewed as well.

Laparoscopic sleeve gastrectomy for linear scleroderma.

Linear scleroderma is a rare type of autoimmune connective-tissue disorder and is one of five known types of localized, nonsystemic scleroderma. This type of localized scleroderma affects the skin and subcutaneous tissues and induces extensive fibrosis and atrophy of the affected limbs. The disease is, characteristically, a unilateral phenomenon and usually affects the lower extremities. Due to its underlying pathophysiology, linear scleroderma is rarely associated with morbid obesity. This article documents the case of a 45-year-old female with a 35-year history of unilateral linear scleroderma, who subsequently developed morbid obesity of her contralateral side. Due to her linear scleroderma, she was unable to exercise effectively and developed hemiobesity associated with arthritis, lower back pain, and hypercholesterolemia. Based on her hemiobesity and associated comorbidities, she underwent a laparoscopic sleeve gastrectomy. Postoperatively, she has lost 20 kg or 75% of her excess weight, with a resolution of joint and back pain and hypercholesterolemia at 12-month follow-up. This article describes a unique application for a sleeve gastrectomy in the setting of linear scleroderma and hemiobesity.