Management of complications after laparoscopic Roux-en-Y gastric bypass.

Obesity has become an increasing problem in developed countries and laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the leading treatments for this disease. Although studies show that it is effective in reducing weight and lessening comorbidities, both early and late complications can occur. Early complications include venous thromboembolism, anastomotic leak, and hemorrhage. Late complications include obstruction, anastomotic stenosis, fistula, ulcer, cholelithiasis and nutritional deficiencies. Diagnosis of these complications is often challenging due to the lack of specificity of the presenting signs and symptoms. A high index of suspicion for detecting these complications is universally advocated. Fortunately, mortality from this procedure is rare. Management of the complications is generally consistent with basic surgical principles and surgical reinterventions can often be performed either endoscopically or laparoscopically depending on the situation and the surgeon's expertise. The available literature is confounded by mixing of results between open and laparoscopic techniques as well as the substantial differences in technique between authors reporting their outcomes. Although there is no consensus for managing the reported complications of LRYGB surgery, this article reviews the current literature and describes the presentation, diagnosis, and management of each of the early and late complications associated with the procedure.

Acute right-lower-quadrant mass presenting after laparoscopic cholecystectomy.

Hernia formation at trocar sites has been reported following laparoscopic surgical procedures. We present a case, however, of a healthy woman with signs, symptoms, and physical findings consistent with an incarcerated inguinal hernia 3 days after an uneventful laparoscopic cholecystectomy. Exploratory laparotomy revealed a small bile leak from an accessory duct of Luschka but did not identify an intra-abdominal process responsible for the patient's symptoms. Following the exploration, it was felt that the patient's presentation was likely due to tracking of carbon dioxide and bile-stained irrigation fluid to the right lower quadrant from the lateral laparoscopic trocar sites.

Tumor necrosis factor-alpha-induced apoptosis in hepatocytes in long-term culture.

Apoptosis occurs naturally in the liver and increases in specific pathogenic processes. We previously described the use of a chemically defined medium supplemented with epidermal growth factor and dimethylsulfoxide to maintain rat hepatocytes in a highly differentiated state for more than 30 days (long-term culture). In this study, we showed that hepatocytes in long-term dimethylsulfoxide culture have definite advantages over using cells in short-term culture (cells in culture for 2 to 4 days) to study apoptosis. We demonstrated that treatment with tumor necrosis factor (TNF)-alpha induced apoptosis (detected morphologically and by formation of an oligonucleosomal DNA ladder) only in hepatocytes that had been subjected to dimethylsulfoxide removal. Neither treatment with TNF-alpha alone or dimethylsulfoxide removal alone induced apoptosis. Apoptosis could be induced by concentrations as low as 500 U of TNF-alpha/ml. Although a DNA ladder was not detected by 12 hours after TNF-alpha treatment, it was easily identified by 24 hours. We conclude that this system can be used 1) to examine the underlying mechanism by which TNF-alpha causes apoptosis in hepatocytes and 2) to study induction of apoptosis in hepatocytes by other agents.

Gallstone umbilical sinus tract formation following laparoscopic cholecystectomy.

The use of laparoscopic techniques in general surgical procedures has increased dramatically in the past 6 years. A number of articles in the literature have described a multitude of complications arising from these techniques. We report the development of a draining umbilical sinus tract following laparoscopic cholecystectomy, arising as a result of gallstone fragmentation during gallbladder removal. Despite aggressive local treatment, there was no improvement in the condition of the umbilical trocar site, necessitating wide excision of the umbilicus and trocar site. Although subcutaneous abscesses from gallstone fragments have been reported in the literature, to our knowledge this is the first report in which the subsequent development of a sinus tract required a second operative procedure for resolution. In addition, we suggest several methods for the prevention of abscess or sinus tract formation following laparoscopic cholecystectomy.

Experience with the double lumen Silastic catheter for hemoaccess.

Transvenous access for acute hemodialysis has advanced recently with the introduction of a double lumen Silastic (silicone rubber), Dacron-cuffed (polyester) catheter (Quinton PermCath), which has a better patient acceptance than the stiff Teflon (polytetrafluoroethylene) catheters. We present our experience with 53 PermCath catheters placed in 49 patients (eight to 80 years old). Twenty-two catheters were used for initiation of dialysis, 17 as a bridge to permanent hemoaccess, two as a bridge to peritoneal dialysis and 12 for chronic hemoaccess. We have achieved better success with insertion of catheters through the jugular system (external in 22 instances and internal in 30) by cutdown with fluoroscopic positioning of the catheter tip at the second to third intercostal space. Arterial port alignment was toward the center of the vena cava to reduce sucking against the caval wall during dialysis. No catheter failed to function with this positioning technique. Average catheter use was 84 days with a range of one to 573 days. Catheter thrombosis occurred 40 times in ten patients and was treated successfully in all with the infusion of streptokinase or urokinase. Four patients received chronic warfarin for repeated clotting. Four patients had catheter sepsis that resolved with removal of the catheter and administration of antibiotics. We conclude that the PermCath is an improved means for hemoaccess with a low complication rate. Our key to successful functioning of the PermCath is careful fluoroscopic positioning of the catheter tip.

Hemodynamic effects of a new right ventricular assist device.

A right ventricular assist device (VAD) based on the principle of counterpulsation has been developed at our institution. The device is a valveless, pneumatically actuated, 40 cc, sac-type pump, with a single inlet-outlet port. For right ventricular support, the "Uniport" pump is anastamosed end-to-side to the pulmonary artery. In previous experimental trials, the device has been shown to impart minimal trauma to blood components. In this study, biventricular failure was induced in eight Holstein calves by normothermic ischemia during cardiopulmonary bypass. A Pierce-Donachy left VAD (LVAD) was used for left ventricular support following the ischemic insult. Hemodynamic measurements were obtained throughout the study, and each animal served as its own control. A significant increase in post injury cardiac output (33.5 +/- 11.4%) was obtained with use of the Uniport and LVAD, as compared to use of the LVAD alone (p less than or equal to 0.005). Other hemodynamic parameters of right heart failure, including right atrial pressure (RAP), pulmonary artery pressure (PAP), and left atrial pressure (LAP) were not significantly affected. These data suggest that the Uniport right ventricular assist device significantly improves cardiac output in this model of moderate right ventricular failure. Additional studies are required, however, to optimize pump stroke volume, and to further define the performance envelope of the device.