Pancreatic resection in octogenarians.

BACKGROUND: Few studies exist that evaluate outcomes of pancreatectomy in patients > or =80 y of age, an age group increasing in size in the United States. This study analyzes the outcomes of pancreatectomy in patients > or =80 y of age. METHODS: The medical records of 32 patients > or =80 y of age undergoing pancreatectomy at our institution from April 1995 through October 2008 were reviewed, and outcomes were analyzed. RESULTS: The median patient age was 82 y, and 75% were ASA Class 3. Eighty-one percent of the resections were pancreaticoduodenectomies. There were no operative deaths. Sixty-six percent of patients suffered at least one complication. The median length of stay was 11 d. Eighty-one percent of the resections were performed for cancer. Median survival for all patients was 14.4 mo. Median survival for patients with cancer was 12 mo versus 103 mo for patients without cancer, P = 0.017. CONCLUSIONS: Pancreatectomy in patients > or =80 y of age can be performed with a low risk of mortality but with significant morbidity.

A technique for MRI-guided transrectal deep pelvic abscess drainage.

OBJECTIVE: The purpose of this article is to introduce a technique for transrectal drainage of deep pelvic abscesses performed under interactive MRI guidance. CONCLUSION: A new method for triorthogonal image plane MRI guidance was developed and used to interactively monitor the puncture needle on continuously updated sets of adjustable three-plane images. The merits and limitations of the technique are highlighted and the patient population that is likely to benefit from this approach is suggested.

Eliminating respiratory intensive care unit stay after gastric bypass surgery.

BACKGROUND: The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis. PATIENTS AND METHODS: From 1998 to 2005, 890 bariatric procedures were performed at our center: 858 primary gastric bypasses and 32 revisions. Before 2004, patients were evaluated selectively for OSA; after 2004, all patients have had a sleep study. RESULTS: A postoperative ICU stay was required in 43 patients (5%). From 1998 to 2003, when OSA evaluation was not mandatory, a respiratory-related ICU stay was necessary in 11 of 572 patients. When OSA evaluation was mandated in all patients (2004-2005), there was one respiratory related ICU stay (1/318). CONCLUSION: Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.

Avoidance of complications in older patients and Medicare recipients undergoing gastric bypass.

HYPOTHESIS: Perioperative morbidity and mortality do not increase in carefully evaluated and managed Medicare and elderly patients undergoing gastric bypass. DESIGN: Retrospective review of a prospectively maintained bariatric database. SETTING: Academic tertiary care medical center. PATIENTS: We reviewed our database of 928 consecutive patients who underwent gastric bypass from March 24, 1998, through May 31, 2006. Of these patients, 36 underwent revision surgery and were excluded. The remaining 892 patients were separated into 4 groups by age and Medicare status. Group 1 consisted of 46 patients 60 years or older at the time of gastric bypass (range, 60-66 years). Group 2 consisted of 846 patients 59 years or younger at the time of gastric bypass (range, 18-59 years). Group 3 consisted of 31 Medicare recipients (age range, 31-66 years). Group 4 consisted of 861 non-Medicare recipients (age range, 18-64 years). MAIN OUTCOME MEASURES: Groups were compared in terms of demographics, morbidity, and mortality. RESULTS: No differences were found in outcomes between older vs younger and Medicare vs non-Medicare patients for any postoperative complication or mortality. CONCLUSIONS: Bariatric surgery can be performed in carefully selected Medicare recipients and patients 60 years or older with acceptable morbidity and mortality. No difference was found in the occurrence of complications in Medicare patients, patients younger than 60 years, or patients 60 years and older. We believe that these results reflect careful patient selection, intensive preoperative education, and expert operative and perioperative management. Our results indicate that bariatric surgery should not be denied solely based on age or Medicare status.

Long-term central venous catheters: size and location do matter.

BACKGROUND: Right or left side of placement for subclavian vein catheterization for placement of long-term central catheters and size of the catheters has not been analyzed completely. METHODS: The records of 502 consecutive long-term central venous catheters placed in patients while in the operating room over a 1-year period were reviewed and 230 subclavian vein tunneled catheters were analyzed. Technical difficulties in placing the catheters were defined as arterial puncture, guidewire malposition, catheter malposition, need to switch site of access, sheath difficulty, and inability to place the catheter. RESULTS: Three complications were identified (1%) and technical difficulties occurred in 15% of the patients. More difficulty was associated with the insertion of larger triple-lumen catheters than smaller single-lumen catheters (31% vs. 11%, respectively; P < .009). Right subclavian placement was associated with a 24.4% technical difficulty rate versus a 10.4% technical difficulty rate for left subclavian placement (P < .005). CONCLUSIONS: This study supports placing the smallest catheter necessary via the left subclavian vein.

Two-day length of stay following open Roux-En-Y gastric bypass: is it feasible, safe and reasonable?

BACKGROUND: As our bariatric program matured, we noted that length of stay (LOS) steadily decreased. This led us to analyze our experience to identify factors contributing to this abbreviated LOS and to evaluate the safety of discharging patients with only a 2-day LOS. METHODS: All patients undergoing open Roux-en-Y gastric bypass (RYGBP) from March, 1998 to December 31, 2002 were evaluated. Contrast swallow study was performed on Day 1. Patient demographics, complications, and readmission rates were reported for all patients. Discharge criteria included adequate oral intake, pain control with oral analgesia, and an adequate understanding of the operation and its effects demonstrated by a written test before discharge. RESULTS: 316 patients underwent open RYGBP with mean BMI 52.3. Operative time decreased from 241 minutes in 1998 to 156 minutes in 2002. No patient was discharged at 2 days during the first 2 years of the program. In 2000, 1 of 52 patients (2%) went home on the second day. In 2001, the year we fully enacted our multidisciplinary approach, 14 of 96 patients (15%) returned home on the second day. In 2002, 73 of 145 patients (50%) were discharged on the second postoperative day, with no increase in readmission rates. Three of the 73 patients (4.1%) required readmission within 30 days of discharge. No difference in co-morbid diseases or BMI was noted between groups. CONCLUSIONS: Our data support the hypothesis that patients undergoing open RYGBP can be discharged safely at Day 2, provided that aggressive preoperative education and screening are performed.

Guidelines for identification and management of outpatient percutaneous endoscopic gastrostomy tube placement.

INTRODUCTION: We sought to determine if percutaneous endoscopic gastrostomy (PEG) could be safely performed in an outpatient fashion. METHODS: One hundred consecutive inpatient (IP) and outpatient (OP) PEGs were analyzed. Patient demographics, PEG indication, nutritional status, complications, and 30-day mortality were determined. Data were analyzed with Student t tests (STTs) and Fisher exact tests (FETs). All OP PEG candidates were evaluated by our dietician, and postprocedure management was discussed before PEG placement. RESULTS: Seventy-four IP and 26 OP PEGs were attempted. All OP PEGs were placed for head and neck cancers, whereas only 18 of 74 (24%) of IP PEGs were performed for that reason (P<.0001 by FET). Mean pre-PEG albumin levels in OP patients were 3.86 g/dL versus 2.79 g/dL for IP patients (P<.0001 by STT). No differences were found in complication rates (OP vs IP, P=.56 by FET). Thirty-day mortality for OP patients was 0% and 9.5% for IP patients. DISCUSSION: OP PEG placement is safe and feasible in carefully selected patients. It requires a care path-driven team approach.

Gastrogastric fistula following Roux-en-Y bypass is attributed to both surgical technique and experience.

BACKGROUND: The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF). METHODS: A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed. RESULTS: Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume. CONCLUSIONS: GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation.

Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality?

BACKGROUND: Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes. METHODS: Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery. RESULTS: We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery. CONCLUSIONS: Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.

Utilization of preoperative patient factors to predict postoperative vitamin D deficiency for patients undergoing gastric bypass.

INTRODUCTION: Vitamin D deficiency occurring after gastric bypass procedures can predispose patients to calcium and parathyroid hormone (PTH) level abnormalities. The aim of the study is to identify preoperative patient risk factors for postoperative vitamin D deficiency. METHODS: We retrospectively reviewed patients who underwent Roux-en-Y gastric bypass procedures between 2005 and 2006. Patient demographics, laboratory values of calcium, vitamin D, and PTH were followed at quarterly intervals for 1 year. RESULTS: One hundred forty-five patients were included in the study. The mean age for the group was 44 years with an average body mass index of 49.5 kg/m(2). Eighty-six percent of patients were female and 23% was African-American. Forty-two percent of the patients had vitamin D deficiency (<20 ng/mL) either preoperatively or at year 1. The mean calcium levels decreased from 9.39 to 9.16 mg/dL (p < 0.001) while the mean PTH levels increased from 25.7 to 43.9 ng/mL (p < 0.001). A logistic regression model recognized preoperative vitamin D levels, race, and bypass limb length to be the only significant factors (p < 0.05) for postoperative vitamin D deficiency. CONCLUSION: It is important to recognize patients who are at risk for vitamin D deficiency before surgery so that early intervention could be in place to minimize further postoperative deficiency.

Early experience with intraoperative radiotherapy in patients with resected pancreatic adenocarcinoma.

BACKGROUND: The use of intraoperative radiotherapy (IORT) in patients with resected pancreatic adenocarcinoma has not been clearly defined. METHODS: The medical records of our first 22 patients receiving IORT for resected pancreatic adenocarcinoma (2001 to 2006) were reviewed and compared with the records of 27 consecutive patients not receiving IORT for resected pancreatic adenocarcinoma (2004 to 2006). RESULTS: There were no 30-day mortalities in either group, and complication rates were similar. Local recurrence occurred in 18% in the IORT group (median 14 months) and 12% in the no-IORT group (median 7 months). Distant recurrence occurred in 47% in the IORT group (median 11 months) and 32% in the no-IORT group (median 6.5 months). Median overall, stage-specific, and location-specific survival did not differ between the groups. CONCLUSIONS: Although limited in size and follow-up, our experience showed that complications, recurrence, and survival were not affected by IORT, but time to recurrence may be longer with IORT.

The impact of resection margin status and postoperative CA19-9 levels on survival and patterns of recurrence after postoperative high-dose radiotherapy with 5-FU-based concurrent chemotherapy for resectable pancreatic cancer.

OBJECTIVES: To analyze the impact of surgical margins and other clinicopathological data on treatment outcomes on 75 patients treated from 1999 to 2006 by initial potentially curative surgery (+/- intraoperative radiotherapy), followed by high-dose 3-dimensional conformal radiation therapy and concomitant fluoropyrimidine-based chemoradiotherapy. MATERIALS AND METHODS: All clinical and pathologic data on this patient cohort were analyzed by actuarial Kaplan-Meier survival methodology and by univariate and multivariate Cox proportional hazards methods to measure effects on survival and patterns of failure. RESULTS: With a median follow-up of 28 months, the median, 2-year and 5-year overall survival (OS) rates were 18.1 month, 41% and 23.6%, respectively. Disease-free survival (DFS) rates were of 11.4 months, 35% and 20%, respectively. Only 2 clinicopathological features, positive (< or =1 mm) surgical margins (P < 0.05) and a 2-fold (>70 U/mL) elevation of the postoperative serum CA19-9 (P < 0.001) impacted OS and disease-free survival. In patients with negative (>1 mm) surgical margins and a low (< or =70 U/mL) postoperative CA19-9, the projected 2- and 5-year OS were 80% and 65%, respectively, compared with 40% and 10% with positive surgical margins and a low CA19-9 and to 10% and 0% with positive or negative surgical margins and a high (>70 U/mL) CA19-9. Positive surgical margins (P < 0.001) and an elevated postoperative CA19-9 (P < 0.001) also predicted early development of distant metastases, whereas isolated loco-regional failure was less common and not affected by these or other clinicopathological features. CONCLUSIONS: Using this fluoropyrimidine-based chemoradiotherapy regimen after surgical resection (+/- intraoperative radiotherapy), positive surgical margins and an elevated (2-fold) postoperative serum CA19-9 level predicted for reduced survival and early development of distant metastatic disease.

Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation.

BACKGROUND: Many patients undergoing bariatric surgery have severe comorbidities, including obstructive sleep apnea (OSA). We suspected that sleep apnea was underdiagnosed in our study population. METHODS: A retrospective chart review of our bariatric database was conducted comparing OSA evaluation based on clinical parameters (Era 1) with mandatory OSA evaluation for all patients (Era 2). RESULTS: In both Era groups approximately 19% of patients presented to our program with an established diagnosis of OSA. In Era 1 this increased to 56% based on clinical parameters and in Era 2 this increased to 91% with mandatory polysomnography testing of all patients. CONCLUSIONS: OSA is grossly underdiagnosed in patients with morbid obesity presenting for bariatric surgery. Clinical evaluation continues to miss a substantial percentage of patients with OSA. Mandatory testing of all patients for OSA with polysomnography before bariatric surgery is recommended.

An aggressive surgical approach is warranted in the management of cystic pancreatic neoplasms.

BACKGROUND: Cystic pancreatic neoplasms encompass a range of benign to malignant disease. Recommendations for surgical management vary. METHODS: Records of patients with cystic pancreatic neoplasms from January 1996 through December 2005 were retrospectively reviewed. RESULTS: Sixty resections were performed for 16 serous cystic neoplasms, 7 mucinous cystic neoplasms (MCNs), and 37 intraductal papillary mucinous neoplasms (IPMNs). Twenty-five percent (15/60) of neoplasms contained invasive cancer. Patients with MCN or IPMN invasive neoplasms experienced significantly diminished overall 5-year survival compared to patients with IPMN carcinoma in situ neoplasms and to patients with MCN or IPMN adenoma/borderline neoplasms (22% vs. 73% vs. 94%, P = .004). CONCLUSIONS: Given the poor long-term survival of patients with cystic pancreatic neoplasms containing invasive cancer and the current difficulty to preoperatively distinguish among the various types of lesions in a reliable manner, our data support an aggressive surgical approach to the management of cystic pancreatic neoplasms.

Increases in parathyroid hormone (PTH) after gastric bypass surgery appear to be of a secondary nature.

INTRODUCTION: Endocrine changes, particularly increases in parathyroid hormone (PTH), occurring after gastric bypass procedures have been reported but are not well characterized. METHODS: We reviewed retrospectively patients who underwent Roux-en-Y (short limb (SL) = 75 cm, long limb (LL) = 165 cm) gastric bypass procedures at our institution from January-December 2005. Patient demographics, laboratory values of serum calcium, Vitamin D, and phosphorous concentrations as well as levels of alkaline phosphate and PTH were followed at quarterly intervals for one year. RESULTS: 140 patients were identified. Mean age for the group was 45 years and 90% of patients were female. The average BMI was 49.2. The mean PTH levels increased from 29.4 immediately post-op to 43.1 ng/mL (P < .001) one year after surgery. Five percent of the patients had hyperparathyroidism (PTH>53 ng/mL) immediately postoperatively; the ratio then increased to 21% at one year. Only two patients had evidence of true primary hyperparathyroidism with increased PTH and hypercalcemia. Sixty percent of patients had at least a 10 ng/mL increase in PTH level at the end of one year, reflecting a 30% increase from baseline levels. Vitamin D deficiency (levels <20 ng/mL) were identified in 45 patients (32%) initially postoperatively and they continued to be low compared to the rest of the population (P = .004). Vitamin D levels did vary with seasonal sun exposure and were greatest in the third quarter (July-September). Sub-analysis of the group showed that patients with LL gastric bypass had lesser Vitamin D concentrations (22 vs 30 ng/mL, P < .01) compared to SL patients. CONCLUSION: Although preoperative endocrine abnormalities are present in patients undergoing gastric bypass procedures, the derangements intensify after gastric bypass surgery. A four-fold increase in patients with elevated PTH deserves special attention. When combined with the concurrent prevalence of low serum Vitamin D and normocalcemia in this population, we propose that this is a disorder of secondary hyperparathyroidism requiring medical treatment with Vitamin D supplementation.

Roux-en-Y gastric bypass for clinically severe obesity: normal appearance and spectrum of complications at imaging.

Surgery currently appears to be the most effective method to curtail the effects of morbid obesity and all of its comorbid conditions. Although the ideal procedure has yet to be devised, Roux-en-Y gastric bypass has proved to be successful for many morbidly obese patients pursuing weight loss and increased health. As the technical aspects of this procedure become less cumbersome and the patient population increases, it is vital for radiologists to be proficient in the specific evaluation of these patients, in order to provide optimal care. Complications can be minimized, managed more efficiently, or prevented with prompt evaluation by the radiologist. It is important to appreciate the patency of both the gastrojejunostomy and the jejunojejunostomy, as well as adequate progression of contrast material before the patient is discharged (preferably 24-72 hours after surgery). Follow-up complications include anastomotic leak, staple-line disruption, stomal stenosis, occlusion of the Roux limb, small-bowel obstruction due to adhesions or internal hernia, and obstruction of the enteroenterostomy leading to acute gastric distention. These complications may be life threatening, since clinical symptoms are often inconclusive. To achieve optimal outcome, therefore, conventional radiographic and computed tomographic studies should not be delayed.

Initial presentation of Crohn's disease in pregnancy: report of a case.

PURPOSE: This study evaluates the current morbidity and mortality of Crohn's disease presenting for the first time in pregnancy. METHODS: A review of the English-language literature was performed to collect all reported cases of Crohn's disease presenting in pregnancy. RESULTS: This review demonstrates a maternal mortality of 4 percent and morbidity of 40 percent and a fetal mortality of 38 percent, with 24 percent normal outcome of pregnancy. CONCLUSIONS: This study shows improved maternal and fetal outcome compared with earlier data.