Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients.

BACKGROUND: We present a case of a morbidly obese patient with previous laparoscopic Nissen fundoplication (LNF) who was successfully treated by revision to a laparoscopic Roux-en-Y gastric bypass (RYGB) and discuss our collective experience. METHODS: Between June 2000 and April 2006 seven morbidly obese patients with mean body mass index (BMI) of 39.4 kg/m(2) underwent laparoscopic revision of LNF to RYGB by our group. Important steps of the revision include lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. RESULTS: There was one (14.3%) conversion. Mean operative time (OT) was 324 (206-419) minutes and length of stay was 4.9 (3-8) days. Early complications occurred in 3/7 (42.9%) patients including a staple line hemorrhage without a need for re-exploration, a small pulmonary embolism without hemodynamic instability and a small-bowel obstruction due to a pre-existing incisional ventral hernia that was not repaired on original operation. There were no anastomotic leaks or deaths. At a mean follow-up of 32.9 (12-39) months, mean percentage excess weight loss was 79.5% and 18/28 (64.3%) comorbid conditions were improved or resolved. Gastroesophageal reflux disease (GERD) evaluation with the GERD health-related quality of life (GERD-HRQL) scale showed a significant reduction of GERD scores postoperatively (16.7 versus 4.4). CONCLUSIONS: Although laparoscopic RYGB after antireflux surgery is technically difficult and carries higher morbidity, it is feasible and effective in the treatment of recurrent GERD in morbidly obese patients.

Intussusception after laparoscopic Roux-en-Y gastric bypass.

Intussusception after open Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication. We present a retrospective review of three cases of antegrade intussusception occurring after laparoscopic RYGBP. To our knowledge, these are the first documented cases of intussusception after laparoscopic RYGBP. We describe the clinical presentation and our management of these three cases. Furthermore, we believe that the initial clinical presentation, radiographic findings, and management of these patients may be different than those patients who have undergone an open RYGBP. With increasing popularity of laparoscopic RYGBP, we are likely to see more of this entity.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: lessons learned.

OBJECTIVE: Repair of esophageal atresia and tracheoesophageal fistula has traditionally been performed via thoracotomy. This study aims to evaluate the feasibility and pitfalls of the thoracoscopic approach. MATERIALS AND METHODS: Six consecutive patients with type C tracheoesophageal fistulae underwent thoracoscopic repair. The operation was approached through the right chest using a three-trocar technique (two 5-mm and one 3-mm) with the patient placed in a three-quarter prone position. Patient characteristics, operative time, duration of narcotic usage, conversion factors, postoperative complications, and long-term follow-up were recorded. RESULTS: Five of six patients were successfully operated on thoracoscopically. The average operative time was 143 minutes (range, 75-215 minutes) with repair of long-gap defects requiring significantly longer times than short-gap defects (200 vs. 129 minutes, P < 0.05). There were no intraoperative complications. Mean duration of narcotic use was 52 hours (range, 24-72 hours). There were no anastomotic leaks. One patient developed an anastomotic stricture at the third postoperative week, which resolved with two dilations. One patient died on the first postoperative day from respiratory failure. CONCLUSION: Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula is feasible, but is technically challenging. Long-gap defects require more extensive dissection and difficult anastomosis, and are therefore associated with longer operative times. More data are needed for further evaluation of this approach.

Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery.

HYPOTHESIS: An increase in national utilization of bariatric surgery correlates with the dissemination of laparoscopic bariatric surgery. DESIGN: Evaluation of Nationwide Inpatient Sample data from 1998 through 2002. SETTING: National database. PATIENTS: A total of 188,599 patients underwent bariatric surgery for the treatment of morbid obesity. MAIN OUTCOME MEASURES: Annual total number of bariatric operations, the proportion of Roux-en-Y gastric bypass vs gastroplasty, the proportion of laparoscopic cases, postoperative length of stay, crude in-hospital mortality, and the number of institutions that perform bariatric surgery. RESULTS: Between 1998 and 2002, the number of bariatric operations increased from 12,775 cases to 70,256 cases. The rate of bariatric surgery increased from 6.3 to 32.7 procedures per 100,000 adults. Laparoscopic bariatric surgery increased from 2.1% to 17.9%. The number of bariatric surgeons with membership in the American Society for Bariatric Surgery increased from 258 to 631, and the number of institutions that perform bariatric surgery increased from 131 to 323. During this 5-year period, the annual rate of laparoscopic bariatric surgery increased exponentially (by 44-fold) compared with a linear growth in open bariatric surgery (by 3-fold). CONCLUSIONS: Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States, a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery.

Trends in utilization and outcomes of laparoscopic versus open appendectomy.

BACKGROUND: Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. METHODS: Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. RESULTS: Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260). CONCLUSIONS: Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.

Laparoscopic Roux-en-Y gastric bypass vs. laparoscopic adjustable gastric banding for treatment of morbid obesity.

Bariatric surgery is a rapidly growing discipline in General Surgery. Roux-en-Y gastric bypass (GBP) is currently the most commonly performed bariatric surgical procedure for treatment of morbid obesity in the United States (U.S). The laparoscopic approach to (GBP) has led to a greater acceptance for surgical treatment of morbid obesity by the public and, in return, more surgeons are becoming interested in learning laparoscopic bariatric surgery to meet the high demand. Laparoscopic adjustable silicone gastric banding was approved in the U.S. by the Food and Drug Administration (FDA) for clinical use in 2001, and is emerging as an alternative laparoscopic option in management of morbid obesity. This chapter reviews the indications, techniques, and outcomes of laparoscopic GBP vs. laparoscopic adjustable gastric banding. The advantages and disadvantages of laparoscopic adjustable gastric banding compared to laparoscopic GBP is discussed.

The relationship between hospital volume and outcome in bariatric surgery at academic medical centers.

OBJECTIVE: To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. SUMMARY BACKGROUND DATA: The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as "Centers of Excellence." Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume-outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. METHODS: Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50-100 cases/year), and low-volume hospitals (<50 cases/year). RESULTS: There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). CONCLUSIONS: Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume-outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.

Carcinoid tumors of the common bile duct: report of two cases.

We report two cases of carcinoid tumors of the common bile duct. The first patient was a 65-year-old woman in whom a carcinoid tumor of the distal bile duct was incidentally found during an open cholecystectomy for cholecystitis. The second patient was a 27-year-old man in whom a distal common bile duct carcinoid was incidentally found during orthotopic liver transplantation for sclerosing cholangitis and multiple biliary strictures. There are few reports of carcinoid tumors of the extrahepatic ducts, and a brief review of the relevant literature is discussed following these case reports.