Sleeve gastrectomy to aortic valve replacement: safe?

BACKGROUND: Bariatric surgery has favorable results on cardiac structure and function, but there is minimal research on its utility in the cardiac comorbid population. OBJECTIVES: To determine if laparoscopic sleeve gastrectomy (SG) is safe in patients with symptomatic aortic stenosis (AS). SETTING: Community hospital/bariatric center of excellence in Pennsylvania. METHODS: Retrospective single center review of 18 patients with morbid obesity and clinically significant AS. All SGs were performed between June 2016 and June 2020. Outcomes including hospital length of stay, 30-day readmission, and 30-day mortality in the study population (n = 18) were compared with 100 patients without AS who underwent SG at the same institution during the same time. RESULTS: There were no perioperative deaths. Mean hospital stay in the study group was 1.78 days compared with 1.3 days in the noncardiac group (P = .1154). Two of 18 patients (11.1%) required readmission within 30 days, both for clinically significant bleeding, compared with 2 of 100 noncardiac patients (2.0%) (P = .1097). Seventeen of 18 study patients went on to have definitive aortic valve replacement surgery. CONCLUSION: SG appears safe in patients with clinically significant AS. Although the AS group did have a higher rate of complications, these were manageable and did not increase mortality or LOS. Further studies are required to determine if outcomes of definitive aortic valve replacement are improved after bariatric surgery.

Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plane Block Is Associated With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery performed in North America. As our knowledge of the importance in limiting narcotic use in postoperative patients increases, we sought to evaluate the effect of transversus abdominis plane (TAP) blocks on inpatient narcotic use in patients undergoing LSG. METHODS: A retrospective review of LSG performed at a single institution by 3 bariatric surgeons was performed. All cases over a 15-month period were included, and anesthesia records were reviewed to stratify patients that received a TAP block and those that did not. Demographic, as well as surgical, outcomes were collected for all patients. Narcotic utilization, as reported in morphine equivalents (ME), was evaluated between the 2 groups. RESULTS: 384 LSG patients were identified, of which 37 (9.6%) received a TAP block. There was no statistically significant difference in postoperative morbidity, length of stay, or readmission between groups. Median narcotic utilization in hospital days 1 and 2 in patients with TAP blocks was 49 ME (Interquartile Range (IQR) 14.5-84.5) to 82.5 ME (IQR 57.4-106) in the no-TAP group (P < .001). After controlling for multiple demographic- and patient-related cofactors, multiple linear regression analysis demonstrated TAP block patients utilized 22.48 ME less than the no-TAP group (P < .001) in the first 2 days of their hospitalization. DISCUSSION: Patients that received a TAP block as a part of their perioperative anesthetic care utilized less in-hospital narcotics than those patients that did not receive a TAP block. TAP blocks should be considered as part of a multimodal pain control strategy for patients undergoing LSG.

An unusual presentation of acute cholecystitis: gallbladder volvulus.

Gallbladder volvulus is a rare condition with similar presentation to acute cholecystitis. It is caused by the gallbladder twisting upon its mesentery leading to potential ischemia and biliary obstruction. A 77-year-old female presented with symptoms of right upper quadrant pain and nausea. She was found to have an elevated leukocytosis and a palpable right upper quadrant abdominal mass on exam. Imaging revealed a severely distended gallbladder with pericholecystic fluid and wall thickening without gallstones. Intraoperatively, an extremely distended, ischemic gallbladder was noted to have twisted upon its mesentery. The structures were able to be identified and the gallbladder was able to be safely removed with a laparoscopic approach despite its large size. Gallbladder volvulus is important to consider in the differential of acute cholecystitis because delay in intervention could lead to gallbladder necrosis and possible perforation, increasing the patient's morbidity and mortality.

The da Vinci robotic surgical assisted anterior lumbar interbody fusion: technical development and case report.

STUDY DESIGN: Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5-S1 is detailed. A case report is also presented. OBJECTIVE: To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure. SUMMARY OF BACKGROUND DATA: Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach. METHODS: The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot-assisted approach is presented. RESULTS: The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques. CONCLUSION: The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine. LEVEL OF EVIDENCE: 4.