Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass: Optimal CT Signs for Diagnosis and Clinical Decision Making.

Purpose To evaluate the accuracy of computed tomography (CT) for diagnosis of internal hernia (IH) in patients who have undergone laparoscopic Roux-en-Y gastric bypass and to develop decision tree models to optimize diagnostic accuracy. Materials and Methods This was a retrospective, ethics-approved study of patients who had undergone laparoscopic Roux-en-Y gastric bypass with surgically confirmed IH (n = 76) and without IH (n = 78). Two radiologists independently reviewed each examination for the following previously established CT signs of IH: mesenteric swirl, small-bowel obstruction (SBO), mushroom sign, clustered loops, hurricane eye, small bowel behind the superior mesenteric artery, and right-sided anastomosis. Radiologists also evaluated images for two new signs, superior mesenteric vein (SMV) "beaking" and "criss-cross" of the mesenteric vessels. Overall impressions for diagnosis of IH were recorded. Diagnostic accuracy and interobserver agreement were calculated, and multivariate recursive partitioning was performed to evaluate various decision tree models by using the CT signs. Results Accuracy and interobserver agreement regarding the nine CT signs of IH showed considerable variation. The best signs were mesenteric swirl (sensitivity and specificity, 86%-89% and 86%-90%, respectively; κ = 0.74) and SMV beaking (sensitivity and specificity, 80%-88% and 94%-95%, respectively; κ = 0.83). Overall reader impression yielded the highest sensitivity and specificity (96%-99% and 90%-99%, respectively; κ = 0.79). The decision tree model with the highest overall accuracy and sensitivity included mesenteric swirl and SBO, with a diagnostic odds ratio of 154 (95% confidence interval [CI]: 146, 161), sensitivity of 96% (95% CI: 87%, 99%), and specificity of 87% (95% CI: 75%, 93%). The decision tree with the highest specificity included SMV beaking and SBO, with a diagnostic odds ratio of 105 (95% CI: 101, 109), sensitivity of 90% (95% CI: 79%, 95%), and specificity of 92% (95% CI: 83%, 97%). Conclusion The decision tree with the highest accuracy and sensitivity for diagnosis of IH included mesenteric swirl and SBO, the model with the highest specificity included SMV beaking and SBO, and the remaining signs showed lower accuracy and/or poor to fair interobserver agreement. Overall reader impression yielded the highest accuracy for diagnosis of IH, likely because alternate diagnoses not incorporated in the models were considered. © RSNA, 2016 Online supplemental material is available for this article.

Clinical management of patients presenting with non-adjustable gastric band (NAGB) complications.

BACKGROUND: A number of bariatric surgical procedures have been developed to manage morbid obesity and related co-morbidities. The non-adjustable gastric band (NAGB) was one such procedure that created restriction to food intake by gastric segmentation. Benefits of the procedure included a low risk of perioperative complications and substantial early weight loss. Unfortunately, the long term results of NAGB include a high incidence of complications and failure to maintain weight loss. The purpose of this study was to examine the presentation, workup, and treatment of patients presenting with complications following NAGB placement. METHODS: A retrospective review of the diagnosis and management of 11 patients who presented with complications related to NAGB placement. RESULTS: All patients presented with some degree of proximal gastric outlet obstruction. The majority of patients (8/11) presented with vomiting as the main complaint. Other complaints included intolerance to solids, liquids, and reflux. Only 2/11 patients presented with weight loss since undergoing NAGB placement, while the remainder had weight regain to their pre-NAGB level and above. Depending on clinical presentation, desire for additional weight loss and co-morbid conditions, patients underwent a variety of treatments. This included NAGB removal (endoscopic, laparo-endoscopic, and laparoscopic) as well as conversion to another bariatric procedure (sleeve gastrectomy, Roux-en-Y gastric bypass). CONCLUSION: Patients with NAGB complications present with symptoms related to a proximal gastric outlet obstruction, related to constriction imposed by the band. This may result in severe food and liquid intolerance and subsequent weight loss, but more likely results in maladaptive eating and subsequent weight gain. Optimal therapy involves removal of the NAGB. Laparoscopic conversion to another bariatric procedure, optimally a Roux-en-Y gastric bypass, is warranted to treat morbid obesity and associated co-morbidities.

Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients.

BACKGROUND: Obesity rates have reached epidemic levels with over 300 million obese individuals worldwide. Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG-associated gastric leakage and hemorrhages remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Our objective was to assess staple line buttress reinforcement via the Duet™ tissue reinforcement stapler system in morbidly obese patients undergoing LSG as part of a comprehensive weight management strategy, focusing on postoperative complications. METHODS: Between January 2008 and April 2011, we retrospectively reviewed the medical records of 116 consecutive patients that underwent LSG with staple line buttress reinforcement at an academic teaching hospital with advanced bariatric fellowship. RESULTS: The mean age of patients was 44.3 ± 9.5 years, with mean preoperative BMI of 44 ± 7 kg/m2. The mean operative time to perform LSG was 96 ± 25 min. Postoperative weight was significantly lower following LSG at 1-year follow-up compared to baseline (104 ± 25 vs. 125 ± 27 kg, P < 0.05). There were no postoperative gastric leaks observed. Postoperative bleeding from the gastric staple line occurred in one patient (0.9%) and was treated with conservative management. CONCLUSIONS: In LSG, staple line buttress reinforcement limits postoperative gastric leakage and bleeding in morbidly obese patients.

Assessment of medical student laparoscopic camera skills and the impact of formal camera training.

BACKGROUND: In laparoscopic surgery, the role of camera holder often falls to untrained medical students. Laparoscopic-naive students can easily acquire laparoscopic camera navigation (LCN) skills, yet it is unclear whether this translates into improved LCN performance in the operating room and whether students retain these skills over time. The purpose of this study was to evaluate whether preclinical laparoscopic camera simulator training would result in improved LCN skills, efficiency, and comfort level over the course of a 6-week surgery clerkship. METHODS: A randomized, controlled study was designed to compare students' preclerkship and postclerkship LCN skills on a previously validated box trainer model. The students (n = 70) were randomized via a computer-generated table of random numbers into study and control groups. The study group (n = 36) received a brief laparoscope training session before the clerkship, while the control group (n = 36) did not. All students also completed a preclerkship and postclerkship questionnaire detailing their experience and comfort level. RESULTS: Statistical analysis using Wilcoxon's signed-rank test demonstrated that all students improved in skill level (total score, 4 vs 7; P < .0001), efficiency (time, 76 vs 33 seconds; P < .0001), and comfort level (Likert scale score, 2 vs 4; P < .0001), with no statistically significant difference between the control and study groups. CONCLUSIONS: This study demonstrates that novice medical students are able to gain laparoscopic camera skills from "hands-on" experience, with no added benefit or retention of skills learned in a preclinical camera simulator training session.

A deficiency in knowledge of basic principles of laparoscopy among attendees of an advanced laparoscopic surgery course.

INTRODUCTION: Advanced laparoscopic courses serve as a comprehensive and popular Continuing Medical Education (CME) activity. Knowledge of basic laparoscopy is an assumed prerequisite for attendance at these courses. OBJECTIVE: To determine the baseline laparoscopic knowledge of attendees at an advanced laparoscopic surgical course. METHODS: A.17-question examination was designed using data from the basic laparoscopic quizzes on the Society of American Gastrointestinal Surgeons (SAGES) website (http://www.sages.org/education/quiz). The questions covered 4 realms of basic laparoscopy: access, pneumoperitoneum, camera navigation, and surgical instrumentation. The questionnaire was distributed to all attendees at an advanced laparoscopic course at the 2009 Canadian Surgical Forum organized by the Canadian Association of General Surgeons. RESULTS: Forty-three respondents completed the survey. Fifty-three percent (53%) of responders had been in practice for more than 10 years and 65% had over 5 years experience. Fifty-five percent (55%) [24/43] of respondents listed laparoscopic courses as the sole means of laparoscopic training. Sixty-one percent (61%) [28/43] were performing > 50 laparoscopic cases per year. The median score on the knowledge-based questions was 70.6% [12/17]. In terms of overall score, respondents with more than 5 years experience performed similarly to respondents with less than 5 years experience (73% correct answers). Interestingly, in a subgroup analysis, respondents performed well in camera skills and pneumoperitoneum-themed questions (84% correct answers) but performed poorly on questions pertaining to instrumentation or access (52% correct answers). CONCLUSION: Basic laparoscopic knowledge among the attendees of an advanced laparoscopic course is suboptimal. A review of basic principles of laparoscopy particularly pertaining to instrumentation and access should form part of these CME activities.