Pancreatic pseudocyst-inferior vena cava fistula causing caval stenosis, left renal vein thrombosis, subcutaneous fat necrosis, arthritis and dysfibrinogenemia.

AIM: We describe the case of a 38 year old man, with a story of alcohol abuse, who developed a very painful nodular subcutaneous fat necrosis, fever and polyarthritis, denying any abdominal symptoms due to a pancreatic pseudocyst-inferior vena cava fistula. MATERIAL OF STUDY: The authors discuss the unusual and protracted course with intermittent hyperamylasemia and hyperlipasemia related to clinical manifestations such as subcutaneous fat necrosis, polyarthritis, pleural effusion and dysfibrinogenemia, and vascular complications as inferior vena cava stenosis and left renal vein thrombosis without abdominal symptomatology. RESULTS: After ultrasonograms and CT Scans showing a 3-4 cm cyst at the pancreatic head with a solid bud protruding into the pseudocystic cavity, and an ERCP showing a communication between the pancreatic duct and the pseudocyst but failing in demonstrating the vascular fistula, the patient underwent a Roux-en-y pseudocyst-jejunostomy and suture of the caval communication leading to complete recovery with normalization of laboratory findings. DISCUSSION: In our case, the locally sclerosing activity of the enzymes in the endothelium led to a communication between the inferior vena cava and the pseudocyst and to a complete thrombosis of the left renal vein and to a stenosis of the inferior vena cava itself The fluctuance of the symptomatology severity was probably due to an intermittent opening of the passage between pseudocyst and vena cava. Such a clinical case, to the author knowledge, has never been reported. CONCLUSION: When in presence of very high levels of amylasemia and lipasemia in spite of the paucity of abdominal symptomatology, and the onset of unusual complications such as panniculitis, pleural effusion, arthritis and coagulative disorders, a pancreatic pseudocyst-inferior vena cava fistula should be kept in consideration during diagnosis.

Prophylaxis of venous thromboembolism in bariatric surgery.

Patients with morbid obesity who undergo bariatric surgery are usually considered at high risk of developing venous thromboembolism. Considering that deep vein thrombosis is often asymptomatic, primary prevention is the key to reducing morbidity and mortality. Between 1995 and 2003, 151 patients underwent surgery for morbid obesity at the Obesity Surgery Centre-University of Sassari. At the beginning of our experience in this field, in the first 65 cases, prophylaxis of thromboembolism consisted in a single intravenous injection of heparin sodium at the time of induction of anaesthesia. The dose of heparin ranged from 2500 to 5000 IU according to weight and any diseases associated with obesity. In a later stage of our experience (86 cases) we modified the drug therapy and used low doses of calcic heparin: the dose was obtained by daily monitoring of Pt, TT and aPTT in order to obtain good anticoagulation. This treatment was usually begun 4-5 days before the operation and continued until the patient was discharged (8-9 days). In the first group of patients we had 2 cases (3%) of fatal acute pulmonary embolism. In the second group 1 (1.16%) case of non-fatal pulmonary embolism developed on postoperative day 20. No clear consensus emerges from the literature as to the best approach to reduce the risk of thromboembolism in bariatric surgery to a minimum. Our experience suggests that "personalized heparin prophylaxis" before, during and after bariatric surgery could be the key to reducing morbidity and mortality.

Emergency surgical conditions after biliopancreatic diversion.

BACKGROUND: Urgent late complications of biliopancreatic diversion (BPD) are rare and often require the experience of a bariatric surgery team for their immediate resolution. METHODS: The present work analyzes the incidence of emergency surgical conditions in a group of 138 patients who had undergone classical BPD, with a mean follow-up of 60 months (24-96) after BPD. RESULTS: Urgent surgical intervention was necessary in 9 patients out of 138 (6.5%): 7 (5%) were for intestinal obstruction (4 of the biliopancreatic limb and 3 of the alimentary tract); 2 (1.4%) were for stomal ulcer with complications (1 massive hemorrhage and 1 perforation). CONCLUSIONS: These complications of BPD are common to all GI operations, and thus are not specific to the type of surgery. We emphasize the importance of early diagnosis and treatment, particularly in regard to intestinal obstruction, because delay could have dramatic consequences.

Duodenal switch without gastric resection: results and observations after 6 years.

BACKGROUND: The results on metabolic effects of the classical biliopancreatic diversion (BPD) have led us to investigate the operation without gastric resection, thus preserving stomach and pylorus, in patients who are not seriously obese but suffer from hypercholesterolemia, often associated with type 2 diabetes and hypertriglyceridemia. METHODS: Between 1996 and 1999, we performed the duodenal switch (DS) without gastric resection on 24 mildly obese patients. Mean preoperative BMI was 36.2 kg/m(2). 17 patients (70.8%) suffered from type 1 diabetes, 4 (16.6%) had impaired glucose tolerance, while the remainder had fasting hyperglycemia. In 20 patients (83.3%), hypercholesterolemia and alterations in lipid profile were present. Another 20 patients were taking drugs for arterial hypertension. The pluri-metabolic syndrome was present in 41.6% of patients. RESULTS: Mean follow-up was 4 years. BMI reduction and weight loss were not large. 2 patients who had severe longstanding diabetes type 2 needed a second operation of the classical BPD because of failure in improving diabetes. Another 2 patients were changed to classical BPD because of a relapsing chronic duodeno-ileal ulcer. The incidence of ileal ulcer was 29.1%. Regarding hypercholesterolemia, hypertrigliceridemia, and type 2 diabetes when there is a good pancreatic "reservoir", the operation seems effective in the long-term. Protein absorption is better than that obtained with the classical BPD. CONCLUSIONS: Our long-term results suggest that in carefully selected patients suffering from serious hypercholesterolemia or type 2 diabetes with insulin reserves still at an acceptable level, and with BMI 30-40, DS without gastric resection can be proposed as a surgical treatment for metabolic diseases but not for obesity.

Impact of age on long-term complications after biliopancreatic diversion.

BACKGROUND: The aim of the study is to evaluate the importance of age on the mid- and long-term results and complications after biliopancreatic diversion (BPD). METHODS: Our study comprises 132 morbidly obese patients who underwent Scopinaro BPD from February 1995 to April 2001, with follow-up from 24 to 96 months. The patients, 53 males (40%) and 79 females (60%), with mean preoperative BMI 50.2 (35.4-81.5), and mean age 42 (20-65), were divided in 4 groups. Group A age 20-35, 43 patients; Group B age 36-45, 33 patients; Group C age 46-55, 31 patients and Group D age >55, 25 patients. Incidence of long-term specific complications after BPD were analyzed, including protein malnutrition, reversals, anastomotic ulcer, and incisional hernia. RESULTS: Mean postoperative BMI was similar in all Groups. After 60 months the following BMI values were observed. Group A 30.8, Group B 34.9, Group C 35.9, Group D 32. Incidence of long-term complications were not significantly different (chi(2)) in the 4 Groups, and were respectively: protein malnutrition 6.9%, 12.1%, 6.4%, 16.0%; anastomotic ulcer 11.6%, 9%, 6.4%, 16.0%; reversal 2.3%, 9.0%, 1.32%, 8.0%; ventral hernia 34.8%, 45.4%, 54.8%, 32.0%. CONCLUSIONS: From the preliminary results, it appeared that the incidence of the complications was higher in group D (>55 years old), whereas group C (46-55 years old) showed a lower complication rate. However, the prevalence of complications in all groups was not statistically different on chi(2) analysis. No age limit for bariatric surgery could be determined from the age ranges studied.