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1.
Surg Obes Relat Dis ; 6(1): 68-71, 2010.
Article in English | MEDLINE | ID: mdl-19837011

ABSTRACT

BACKGROUND: The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse. METHODS: The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm(3) was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus. RESULTS: Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve. CONCLUSION: The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.


Subject(s)
Disease Models, Animal , Gastroplasty/adverse effects , Stomach Diseases/etiology , Animals , Dogs , Esophagus/physiopathology , Gastroplasty/methods , Laparoscopy , Male , Pressure , Prolapse , Suture Techniques
2.
Obes Surg ; 18(12): 1581-6, 2008 Dec.
Article in English | MEDLINE | ID: mdl-18648895

ABSTRACT

BACKGROUND: A standard approach for postoperative analgesia in laparoscopic surgery is to infiltrate the incisions with local anesthetic in combination with systemic opioids. The intraperitoneal introduction of local anesthetic in this setting has the potential to provide appropriate analgesia without the side effects of systemic opioids. We performed a randomized clinical trial of the On-Q pump delivery system to determine the safety and efficacy of this device for this novel purpose. METHODS: Thirty patients undergoing laparoscopic adjustable gastric banding were randomly assigned to one of two groups. The treatment group received On-Q pump systems filled with 0.375% bupivacaine, while the control group received pumps filled with 0.9% normal saline. The pump's catheter was introduced intraperitoneally, and bupivacaine or saline was then delivered for the first 48 h after surgery. Patient's subjective pain scores were evaluated at preset intervals. In addition, shoulder pain, morphine requirements, and anti-emetic requirements were tabulated. RESULTS: A statistically significant decrease in patient's subjective reports of pain by visual analog score was noted in the On-Q group 1.8+/-1.93 vs. control 3.5+/-2.4, p<0.046 and remained significant until the end of the study (48 h). No statistical difference was noted in shoulder pain, morphine requirements, or anti-emetic requirements at any time point. CONCLUSION: Our trial was able to provide evidence of significant reduction in postoperative pain as measured by subjective pain scores with the use of continuous intraperitoneal bupivacaine using the On-Q pain pump system. Further investigation is warranted to evaluate the cost effectiveness of this technique.


Subject(s)
Anesthetics, Local/administration & dosage , Bupivacaine/administration & dosage , Gastroplasty , Pain, Postoperative/prevention & control , Adult , Double-Blind Method , Female , Humans , Infusions, Parenteral , Laparoscopy , Male , Middle Aged , Obesity, Morbid/surgery , Pain Measurement , Prospective Studies
3.
Obes Surg ; 15(5): 618-23, 2005 May.
Article in English | MEDLINE | ID: mdl-15946450

ABSTRACT

BACKGROUND: Previous studies have reported that risk factors for elevated mortality after Roux-en-Y gastric bypass include male gender, as well as a very elevated BMI. The present study was aimed at determining whether these same risk factors applied to patients undergoing the duodenal switch (DS) operation. MATERIALS AND METHODS: A retrospective chart review was performed of a cohort of 385 patients who underwent DS. The 30-day mortality of super-superobese (SSO) patients [BMI > or =60 kg/m2 (n=102)] was compared with the mortality of the super- and morbidly obese (SMO) patients [35 or =60 kg/m2.


Subject(s)
Duodenum/surgery , Obesity, Morbid/mortality , Obesity, Morbid/surgery , Adult , Chi-Square Distribution , Comorbidity , Female , Humans , Logistic Models , Male , Postoperative Complications , Retrospective Studies , Risk Factors , Sex Factors , Treatment Outcome
4.
Obes Surg ; 15(1): 64-9, 2005 Jan.
Article in English | MEDLINE | ID: mdl-15760500

ABSTRACT

BACKGROUND: Recent data has shown that the use of warmed, humidified carbon dioxide (CO2) insufflation during laparoscopic surgery may be associated with better outcomes. METHODS: We performed a randomized, doubleblind, prospective controlled clinical trial of 30 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Patients were randomized into 2 groups. The first group (group 1, n=15) received standard (dry, room temperature) CO2 for insufflation during the surgery, while the second group (group 2, n=15) received warmed (35 degrees C) and humidified (95%) CO2. Patients received postoperative analgesia from morphine delivered via a patient-controlled analgesia (PCA) pump. Pain scores (on a scale of 0 to 10, 0 being no pain and 10 being the worst pain) were measured postoperatively at 3 h, 6 h, 1 day and 2 days. The amount of morphine that was delivered through the PCA was also measured at the same time intervals. Operating-room (OR) time, core temperature, and total hospital length of stay were documented. RESULTS: Postoperative pain as documented by pain scores and narcotic usage were not statistically different in the 2 groups. We demonstrated a statistically significant difference (mean+/-SD) in OR time (76+/-16 min vs 101+/-34 min, P=0.02), total hospital length of stay (3.2+/-.4 days vs 4.0+/-.9 days, P=0.01) and end-of-case core temperature (36.2+/-.5 degrees C vs 35.7+/-.6 degrees C, P=0.02) in group 2 compared with group 1. CONCLUSION: The use of warmed, humidified CO2 insufflation in bariatric patients undergoing LRYGBP was not associated with any significant benefit with regards to postoperative pain.


Subject(s)
Gastric Bypass/methods , Laparoscopy/methods , Obesity, Morbid/surgery , Pneumoperitoneum, Artificial/instrumentation , Adult , Anastomosis, Roux-en-Y/adverse effects , Anastomosis, Roux-en-Y/methods , Body Mass Index , Carbon Dioxide/pharmacology , Double-Blind Method , Female , Follow-Up Studies , Gastric Bypass/instrumentation , Humans , Humidity , Length of Stay , Male , Middle Aged , Obesity, Morbid/diagnosis , Pain, Postoperative/physiopathology , Pneumoperitoneum, Artificial/methods , Probability , Prospective Studies , Risk Assessment , Severity of Illness Index , Statistics, Nonparametric , Temperature , Treatment Outcome
5.
Obes Surg ; 14(1): 107-15, 2004 Jan.
Article in English | MEDLINE | ID: mdl-14980044

ABSTRACT

BACKGROUND: Severe sepsis syndrome (SSS) and septic shock have an associated mortality ranging from 31 to 60%. Drotrecogin alfa (activated), activated protein C (APC), has been shown in a recent trial to decrease mortality from 44 to 31% in patients with SSS and a high risk of death. We present 3 patients who developed SSS after bariatric surgery and were treated with APC as part of comprehensive therapy for sepsis. METHODS: At our institution, patients must have SSS plus an APACHE II score >or= 25 in order to receive APC. JL is a 43-year-old man who developed SSS (APACHE II score 26) after Roux-en-Y gastric bypass. ML is a 33-year-old man who developed SSS (APACHE II=28) because of a distal obstruction 2.5 years after gastric bypass surgery. TQ was a 35-year-old man who developed SSS (APACHE II=35) in the setting of laparoscopic banding. RESULTS: After receiving 90% of the 96-hour infusion, JL developed ecchymoses and a decrease in his platelet count; thus, the drug was stopped. ML received a full 96-hour infusion. Both patients made a full recovery from their SSS and were successfully discharged from the hospital. TQ developed septic shock and expired despite all efforts. CONCLUSION: Weight alone should not be considered a contraindication to the use of APC. Close coordination between the intensivist and surgeon is recommended for bariatric surgery patients with SSS, so that a rapid determination can be made as to the patient's risk of death and eligibility to receive APC.


Subject(s)
Anti-Infective Agents/therapeutic use , Gastric Bypass , Postoperative Complications/drug therapy , Protein C/therapeutic use , Recombinant Proteins/therapeutic use , Systemic Inflammatory Response Syndrome/drug therapy , Adult , Fatal Outcome , Gastric Bypass/methods , Humans , Laparoscopy , Male , Obesity, Morbid/surgery , Systemic Inflammatory Response Syndrome/etiology
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