Application of the POSSUM system in bariatric surgery.

BACKGROUND: The POSSUM system has been devised for physiologic and operative scoring. The scoring system produced assessment for morbidity and mortality rates, which did not significantly differ from observed rates. The authors have applied this system to bariatric surgery. PATIENTS AND METHODS: 20 patients were scored by the POSSUM system. All underwent elective bariatric surgery during 1997. All patients were scored at the time of surgery with the physiologic score (FIS) and at discharge with the operative severity score (IQ). The FIS score included age; cardiac signs; chest radiograph; respiratory history; blood pressure; pulse; Glasgow coma score; determinations of hemoglobin, leukocyte, urea, sodium, and potassium levels; and electrocardiogram. The IQ score included multiple procedures, total blood loss, peritoneal soiling, presence of malignancy, and mode of surgery. RESULTS: The mean POSSUM score was 23.9. The mean FIS was 13.95 (12-22), and the mean IQ was 9.4 (7-16). The distribution of patients was performed for BMI. The group with BMI 35-45 (n = 4 patients) had a mean POSSUM score of 22.75, a mean FIS of 13.75, and a mean IQ of 9.0. The group with BMI >45 (n = 16 patients) had a mean POSSUM score of 24.18, a mean FIS of 14.62, and a mean IQ of 9.5. The morbidities were gastric fistula with peritonitis and deep venous thrombosis. The two complications had similar POSSUM scores with different BMIs. No mortality was observed. CONCLUSIONS: According to this experience, the POSSUM scoring system appears to provide an indicator of minor risk of morbidity and mortality in bariatric surgery with vertical banded gastroplasty.

Technical alternatives in laparoscopic distal gastric bypass for morbid obesity in a porcine model.

BACKGROUND: Laparoscopic gastric bypass and vertical banded gastroplasty are two procedures used in the treatment of morbid obesity. The authors describe alternative techniques of laparoscopic distal gastric bypass as a modification of the Scopinaro procedure, which were used experimentally in a porcine model. METHODS: Five pigs were used. The laparoscopic procedure was performed with the pigs under general anesthesia after pneumoperitoneum had been achieved. Five or six trocars were used. One port was converted from 12 to 33 mm, and all the other ports were 10-11 mm. The initial surgical technique was similar to that used by others for laparoscopic gastrectomy, except that atraumatic ultracision was used for all the dissection. The stomach was stapled with a linear cutter stapler (Endopath, 31 mm) to create a 50-ml pouch. The ileum was divided with a linear cutter-stapler (Endopath, 31 mm) or ultracision cautery. A long length of ileum was positioned between the stomach pouch and the jejunoileostomy. Only 50-70 cm of terminal ileum was preserved as a common channel. In three animals, the circular stapler (ILS, 21 mm) was used to produce an end-to-side anastomosis. In one animal, two purse-string sutures were handsewn in the ileum and jejunum stumps, and in another two animals, two endoloops were used for the anvil. In two animals, the linear stapler was used to form a side-to-side pouch stomach-ileum and jejunoileostomy anastomosis. In other animals, the two types of anastomosis have been combined. All animals were killed after surgery so that the anastomoses could be evaluated for size and integrity. RESULTS: In all animals, with the circular and linear stapler, both 21 and 13-15 mm anastomoses were intact. CONCLUSION: Distal gastric bypass is feasible laparoscopically, with intact anastomoses.

Orthotopic liver transplantation from a donor with abdominal situs inversus.

The good results reported for liver transplantation have encouraged a much wider application of the procedure, broadening the list of indications and increasing the number of candidates. The shortage of organs for transplantation is a main problem that limits hepatic replacement in the potential recipients. Consequently, the number of contraindications for donor selection has been reduced over the last years. Some factors that were previously thought to preclude successful transplantation have now been relegated to relative contraindications, while others are no longer included. This has frequently led to the use of livers under suboptimal conditions or with anatomical anomalies. This is the case of donors with abdominal situs inversus. In this article, we report an orthotopic liver transplantation using a donor with abdominal situs inversus. Immunosuppressive protocol following surgery was composed of a classic three-drug therapy (cyclosporine, azathioprine, and prednisolone). The modified piggyback technique was performed over the right suprahepatic vein with orthotopic position of the graft. The graft showed good long-term function in the recipient, with a normal hepatic biopsy 5 months after the transplantation. There was no patient readmission or other medical problem after a 2 1/2-year follow-up.

Gastropexy simplifies the use of the right gastroepiploic artery for myocardial revascularization.

Surgical anterior and superior fixation to the diaphragam of a segment of the greater curvature of the stomach simplifies the technical performance of harvesting the right gastroepiploic artery for coronary bypass grafting. Gastropexy avoids objections to the use of this pedicled arterial graft, such as the prolonged dissection time, the limited length of the conduit and the potential damage when abdominal surgery is later required.

Could the piggyback operation in liver transplantation be routinely used?

OBJECTIVE: To determine if orthotopic liver transplantation with inferior vena cava preservation, performed without using caval cross clamping or venovenous bypass, can minimize hemodynamic instability and low renal perfusion pressure. DESIGN: A prospective case series of 44 consecutive adult orthotopic liver transplantations, with a maximum follow-up of 30 months. SETTING: An institutional university referral center. PATIENTS: Between November 1990 and May 1993, 39 consecutive adult liver transplant recipients underwent transplantation with the following primary diagnoses: alcoholic cirrhosis (n = 23), viral cirrhosis (n = 9), primary biliary cirrhosis (n = 2), Wilson's disease (n = 2), primary sclerosing cholangitis (n = 1), fulminant hepatic failure (n = 1), and secondary hepatic malignant neoplasm (n = 1); five had repeated orthotopic liver transplantation. INTERVENTION: Orthotopic liver transplantations were performed using the piggyback technique, but with placement of the vascular clamp on the inferior vena cava laterally instead of across it so that it remained patent throughout the anhepatic stage. Favorable anatomic conditions in the recipients were not considered; venovenous bypass was not used. MAIN OUTCOME MEASURES: Intraoperative hemodynamic profile, blood loss and replacement, surgical time and complications, and patient survival. RESULTS: No significant hemodynamic changes with lateral clamping and no increases in surgical complications, rate of retransplantation, blood product requirements, or survival rate compared with the standard procedure. CONCLUSION: The piggyback operation could be routinely used in orthotopic liver transplantation.

Submammary median sternotomy.

A vertical skin incision is used as routine approach for sternotomy. The resulting scar is often disappointing and the top is visible and unpleasant, especially for young women. In 35 women ranging from 10 to 48 years (mean 29.2 years), median sternotomy was performed via a submammary skin incision. In all cases an open heart surgical procedure was performed. Adequate exposure of the heart was achieved in every case and there were no technical problems related to this approach, no hospital mortality or major complications. The cosmetic result is excellent and this approach is certainly justified in open heart surgery for young women.

Stability of mitral reconstructive surgery at 10-12 years for predominantly rheumatic valvular disease.

All consecutive patients who underwent Duran flexible ring annuloplasty in 1975 and 1976 were reviewed until June 1987. Eighty-seven annuloplasties were performed in 85 patients. Aortic, tricuspid, or both surgeries were simultaneously performed in 44.8%. The hospital mortality was 2.3% (two of 85). Ten patients were lost to follow-up within 2 years after surgery, and there were three late deaths. Thromboembolic events were detected in 18 patients (seven peripheral and 11 central with one death); nine patients had partial recovery, and eight had full recovery. At the time of the thromboembolic event, eight patients were receiving anticoagulants; four, antiaggregants; one, both anticoagulants and antiaggregants; and five, none. Thirteen patients (13 of 73, 17.8%) required reoperation between 1 month and 11 years postoperatively. The valve was replaced in 11 patients, and two underwent a new flexible ring annuloplasty. The cause for reoperation was regurgitation in eight patients (10.9%), for whom the mean interval between operations was 20.6 months (range, 1 month-11 years). Stenosis was the cause for reoperation in five patients (6.8%), for whom the mean interval between operations was 87.8 months (range, 4-11 years). We conclude that reconstructive surgery after 10-12 years of follow-up for this group of predominantly rheumatic patients has an incidence of failure of approximately 18% attributable to incorrect surgery (11%) and restenosis (7%).

Long-term evaluation of the Ionescu-Shiley pericardial xenograft bioprosthesis in the aortic position.

From August 1977 through October 1984, 241 patients underwent aortic valve replacement with the Ionescu-Shiley pericardial valve. There were 130 males and 11 females in this series with an average age of 50.8 years (range 15 to 78 years). Isolated aortic valve replacement was performed in 121 patients (50.2%) and associated cardiac surgery in 120 (49.8%). Valve size was 21 mm or smaller in 107 cases (50.2%). Cumulative duration of follow-up was 1,260 patient-years with a mean follow-up of 5.16 years per patient. Five patients were lost to follow-up. Maximum follow-up was 10.5 years. There were 26 hospital deaths and 15 late deaths (1.19% per pt-yr). The expected 10.5 year actuarial survival rate is 82% +/- 2.9%. Twelve thromboembolic episodes occurred in seven patients--seven central and five peripheral events. The thromboembolic rate was 0.95% per patient-year--32% for patients with isolated aortic valve replacement and 0.63% for patients with concomitant surgery. Freedom from thromboembolic episodes at 10.5 years is 73% +/- 12%. Structural valve deterioration was found in 24 patients (1.9% per pt-yr) with an actuarial freedom from primary tissue failure of 77.5% +/- 5.4% at 10.5 years. Reoperation was required in 39 cases (3.09% per pt-yr)--primary tissue failure (n = 24), paravalvular leak (n = 7), infective endocarditis (n = 6), and valve thrombosis (n = 2).

Successful surgical treatment of a case of listeria monocytogenes endocarditis.

Endocarditis due to listeria monocytogenes is rare with only twenty one cases to our knowledge appearing in the world's literature to date. We report a further case with a successful surgical outcome and stress the importance of surgery in the treatment of infective endocarditis. There is a clear predilection of this organism for the left side of the heart and systemic embolization is frequent. In contrast to other clinical forms of listeriosis, endocarditis has not been associated with debilitating states or immunosuppressive treatments. Though clinical and laboratory data suggest a similarity with other types of bacterial endocarditis, the prognosis is more unfavorable and the mortality rate higher.

Long-term results of conservative repair of rheumatic aortic valve insufficiency.

From July 1974 to January 1986, 50 patients underwent conservative repair for rheumatic aortic valvular disease at our institution. Eleven were male and 39 female, with an average age of 39.5 years (range 17-57). The aortic lesion was associated in all cases with a predominant mitral lesion. Twenty-five also had tricuspid disease which was surgically treated in 17. Twenty-six had aortic regurgitation and 24, a mixed lesion. The surgical techniques used were: (1) commissurotomy, (2) annuloplasty, (3) cusp free edge unfolding and (4) supra-aortic crest enhancement. Two patients had one cusp extended with pericardium. There were 3 hospital deaths (6%). Six patients were lost to follow-up at different periods. Maximum follow-up was 12.58 years with a mean of 7.78 years per patient. Twelve required reoperation with 3 deaths. Three reoperations were due to failure of the mitral bioprosthesis without reoperation on the aortic valve. Of the remaining 9 patients who had aortic and mitral dysfunction, 4 had severe aortic insufficiency. The actuarial freedom from reoperation at 13 years was 75% and the overall actuarial survival was 86%. It is concluded that these surgical techniques can be applied successfully in moderate rheumatic aortic valve disease accompanying a predominant mitral lesion. This is particularly relevant when a mitral reconstruction has been performed.