Bariatric Surgery as the One Route to Achieving Donor Heart Transplantation in a Patient with a Left-Ventricular Assist Device.

Bariatric and metabolic surgery is currently the most effective procedure of achieving and maintaining weight loss. In the case under discussion, a 48-year-old male patient with heart insufficiency and an implanted left-ventricular assist device (LVAD) wanted to reduce his high BMI (48.6 kg/m2), so as to qualify for the heart transplant waiting list. According to the guidelines, he underwent all the required preoperative testing, which included psychosomatic clarifications, determination of endocrinological causes, and a nutritional consultation. During laparoscopic sleeve gastrectomy, a cardiac technician was present to support the anesthetist. After inserting 3 trocars with no complications, the greater curvature was mobilized using Medtronic's bipolar electrothermal vessel-sealing instrument, LigaSure™. The resection was performed with an Ethicon™ endostapler. Postoperative monitoring showed no signs of hemorrhage. The patient's BMI on the day of surgery was 46.8 kg/m2 and consecutively fell to 26.7 kg/m2 1 year after the procedure. Follow-up appointments revealed that the patient was fit and in good health. Thus, the patient's aim of being listed on the transplant list was fulfilled, and at the time of this writing, he is ready to be matched with an organ donor. Because high-BMI patients with inserted LVADs are less likely to receive a donor graft and must remain longer on transplant waiting lists than normal-weight patients, bariatric and metabolic weight loss surgery may lead to a speedier resolution for these high-risk patients.

Primary Sleeve Gastrectomy and Leaks: The Impact of Fundus-Wall Thickness and Staple Heights on Leakage-An Observational Study of 500 Patients.

Introduction: The most feared complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Staple height and fundus-wall thickness might influence such leakage, and this study examined their possible impact on leak incidence. Factors including gender, age, comorbidities, and reinforcement of the staple line were also investigated. Methods: A total of 500 patients between 17 and 71 years of age who were scheduled for LSG were selected to participate in the study. For technical reasons, 53 were excluded. The fundus-wall thickness of 447 patients after LSG was investigated. The impact of staple height, fundus-wall thickness, demographic and medical factors on leak incidence were investigated. Most of our patients (309) were female (69%), while 138 were male (31%). Results: The mean thickness of the proximal fundus wall was 2,904 µm, 3,172 µm in men and 2,784 µm in women. The leak rate was 4.9%. Age, fundus-wall thickness, and BMI showed a strong influence on leak risk, but this effect was significant only for age (p = 0.01). Patient gender and staple size showed no significant influence on the correlation between fundus-wall thickness and leak risk. Gender displayed a small effect of influence on this correlation, with η2 = 0.05. Discussion: Because older age had a significant effect on increasing the risk of staple-line leakage, there is a need for a more specific focus on these patients. Thinner fundus wall and female gender might predispose patients to staple-line leaks, but a significant value could not be reached. Therefore, staple size should remain the surgeon's choice based on clinical experience.

Correction to: Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height-an Observational Cohort Study Fundus Wall Thickness and Leaks.

There is an error in the published article. One patient's gender was mistaken; it has been changed from female to male. Thus, the number of male and female patients in Tables 1 and 2, and the median and p value in Table 2 are incorrect.

Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height-an Observational Cohort Study : Fundus Wall Thickness and Leaks.

BACKGROUND: Staple line leakage is a well-known complication after laparoscopic sleeve gastrectomy (LSG). Gastric wall thickness and the staple height may be determining factors for the occurrence of insufficiencies. To investigate this problem, an observational cohort study was carried out. Investigation concentrated on the gastroesophageal junction close to the angle of His, since this area is at highest risk for a leakage. METHODS: Fundus wall thickness of 141 specimens after LSG was measured by light microscopy at a predetermined location by a blinded pathologist. Furthermore, fundus wall thickness was compared with demographic data, clinical outcome, and the rate of insufficiencies. RESULTS: One hundred forty-one patients, 38 male and 103 female undergoing LSG, between January 2014 and July 2015 were included in the study. Male gender was associated with thicker gastric fundus wall. Overall leak rate was 2.1% (3/141). Median wall thickness of the 3 patients with detected leaks in the study group was thinner compared to the non-leak group (2810 vs. 3249 µm, respectively). DISCUSSION/CONCLUSION: Only male gender correlated with higher wall thickness of the fundus. The fact that all three patients who developed a leak were female, and the fundus of female patients as well as those of the leak group was thinner, indicates that wall thickness may have an impact on the rate of staple line leakage. Further studies with larger patient cohorts are needed.

Postoperative surgical complications after radical axillary lymph node dissection in melanoma disease result in increased pain.

Postoperative pain is one of the major problems caused by the operative trauma. We recorded the postoperative pain of patients who underwent a radical axillary lymph node dissection (RALND) to evaluate the quality of our standardized perioperative pain management program and the influence of surgical complications. Between August 2003 and December 2007, we registered the postoperative level of pain of 111 patients who underwent a therapeutic RALND, using a visual analog scale (VAS). Patients received standardized perioperative pain therapy according to level I of the World Health Organization (WHO) ladder of pain. We registered a VAS score of 10 in patients at rest during the first 3 postoperative days, but after mobilization of the arm, patients had significantly more pain (P < 0.0001). Patients with a postoperative surgical complication needed significantly more central analgesia to reach the same level of pain (P = 0.04) as patients without complication. Level I of the WHO ladder of pain is not enough for patients after an RALND. Patients with a postoperative complication do have increased pain, and use of only peripheral analgesia is insufficient.

Preemptive analgesia reduces pain after radical axillary lymph node dissection.

BACKGROUND: Analyzing prospective data of our melanoma patients, we registered a suboptimal pain score under mobilization after radical axillary lymph node dissection (RALND). We performed a randomized, double blinded clinical trial to investigate the effects of a preemptive Parecoxib analgesic during the perioperative course. MATERIALS AND METHODS: Between October 2006 and December 2007, 32 patients with stage III/IV melanoma underwent therapeutic RALND and were randomized into two groups. Patients received intravenously 40 mg Parecoxib or 0.9% normal saline solution 2 h before RALND. The postoperative treatment and analgetic regime was defined in the study protocol. Main outcome criterion was the pain under mobilization at the first postoperative morning registered via a visual analogue score. Minor criteria were the postoperative complications, fatigue, amount of analgesics, and the day of discharge. RESULTS: Patients receiving a preemptive analgesic had a better outcome after RALND. The pain after mobilization was significantly decreased at the first postoperative morning (P = 0.04). Patients had less fatigue as well (P = 0.05) and the amount of pain medication in the treatment group was reduced (P = 0.04). CONCLUSIONS: Preemptive application of Parecoxib enhances outcome after RALND. A preemptive analgesic with Parecoxib in the perioperative management after RALND of melanoma patients can be recommended.

Intraoperative application of fibrin sealant does not reduce the duration of closed suction drainage following radical axillary lymph node dissection in melanoma patients: a prospective randomized trial in 58 patients.

BACKGROUND: Patients suffering from malignant melanoma often require radical lymph node dissection of the axillary nodal basin. The effects of intraoperative application of fibrin sealant following radical axillary lymph node dissection (RALND) on the incidence of postoperative lymphatic secretion are discussed. To study the effect of intraoperatively applied fibrin sealant following RALND a randomized patient-blinded trial was carried out. METHODS: Fifty-eight patients with axillary lymph node metastases of malignant melanoma underwent therapeutic RALND and were randomized into two groups: 29 patients received 2 cc of fibrin glue intraoperatively and 29 patients were only irrigated with 0.9% saline. The amount of drainage was recorded every 24 h. The main outcome criterion was the duration of drain placement in the wound. Minor criteria were the total amount of fluid and the length of hospital stay. Statistical analysis was performed using Spearman's log-rank correlation and paired t-test. RESULTS: There was no significant difference between the nonfibrin group 5 days (range = 3.6-5.7 days) and the fibrin group 5 days (range = 4.1-8.5 days) (p = 0.701). The total amount of fluid for the nonfibrin group (410 cc, range = 362-727 cc) and that for the fibrin group (503 cc, range = 369-1098 cc) (p = 0.605) and the length of postoperative hospital stay of 6 days (range = 5.4-7) vs. 7 days (range = 5.9-10.7), respectively, were not different between both groups (p = 0.387). CONCLUSION: Considering our study results, we cannot recommend the use of 2 cc of fibrin glue intraoperatively in the prevention of lymphatic secretion in patients undergoing RALND for metastatic melanoma.