Intestinal obstruction from midgut volvulus after laparoscopic cholecystectomy

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small bowel obstruction, rarely is recognized beyond the first year of life. We report a case of unrecognized congenital midgut malrotation that resulted in midgut volvulus, causing intestinal obstruction and requiring emergent reoperation after laparoscopic cholecystectomy. This unusual complication, first reported in 1994, involved a 56-year-old man and resulted in cecal infarction recognized and treated on the second postoperative day. This second case describes a less acute postoperative course, with multiple bouts of partial bowel obstruction leading to two readmissions and finally resulting in a reexploration and definitive treatment on the 19th postoperative day. Received: 16 February 1999/Accepted: 22 March 1999     

Changes in hemostasis after laparoscopic cholecystectomy

Background: The aim of this work was to study hemostasis in laparoscopic cholecystectomy in order to determine if there are any changes that indicate a greater risk of thrombosis. Methods: The study was carried out in 20 patients who underwent laparoscopic surgery for noncomplicated cholelithiasis. The average age was 59.4 years (range, 34–77). A total of 75% were female. Mean operation time was 70 min (ranges 35–120). Pneumoperitoneum at 14 mmHg was performed on all patients, who were positioned in the 30° reverse Trendelenburg position. Postoperative mobilization was acheived in 24 hs and patients were discharged 48 hs after the operation. The control group was composed of 12 patients, who were evenly distributed by age, sex, and length of surgery. These patients underwent Bassini herniorraphy for inguinal hernia without any complications or relapse. The following hemostatic parameters were studied: prothrombin activity (PA), activated partial thromboplastin time (APTT), fibinogen (Fg), anti-thrombin III (ATIII), plasma fibrinolytic activity (PFA), euglobulin fibrinolytic activity (EFA), and D-dimer (D-D). Samples were obtained at the following times: (a) under basal conditions the day before surgery, (b) preoperatively, (c) at the end of the operation, (d) 24 hs after the operation, and (e) On the 7th day following the operation. Results: No patient showed any clinical manifestations of thromboembolic disease immediately after surgery or during a medium follow-up period of 16 months (range, 15–18 months). All hemostatic parameters values were within normal range in the basal samples of both groups. In both groups, the mean value of PA showed a significant decrease (p < 0.05) in the second, third, and fourth basal samples, returning to normal levels by the fifth determination. The mean value of fibrinogen decreased slightly in the second and third samples, increasing significantly with respect to the fourth and fifth determinations in both groups (p < 0.05). The mean value of APTT in both groups was slightly enhanced in the second and third determinations in relation to the first and fifth. The global activity of fibrinolysis (PFA and EFA) increased significantly in the third sample with respect to the other determinations in the group who had laparoscopic surgery (p < 0.005). Only EFA increased in the control group (p < 0.05). D-D decreased in the preoperative second determination followed by a significant enhancement immediate postoperatively (third), and 24 hs (fourth) (p < 0.05); it returned to normal basal values on the seventh day. No significant differences were found between the two groups. Conclusions: These results indicate that laparoscopic cholecystectomy leads to no greater activation of plasma coagulation than low-risk surgery. On the contrary, the increase of fibrinolytic activity in plasma would extend a certain degree of hypocoagulability during surgery, maintaining it for 24 hs and thus possibly reducing thromboembolic risk in patients undergoing this type of surgery. Received: 25 February 1998/Accepted: 18 August 1998     

A simplified laparoscopic technique for mesh placement in ventral hernia repair

The use of a large synthetic mesh for laparoscopic repair of significant ventral abdominal wall defects may be accompanied by technical difficulties resulting from improper orientation and positioning of the mesh over the defect. We suggest a technique based on initial fixation of the mesh center to the central point of the defect, and subsequent centrifugal attachment of the mesh to the abdominal wall. This technique is advantageous because it leads to precise orientation and positioning of the synthetic patch and to significant reduction of the time needed for its reinforcement over and around the defect. Received: 25 September 1998/Accepted: 27 November 1998     

Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy. Received: 29 June 1998/Accepted: 2 July 1999     

Laparoscopic Surgery for Genuine Stress Incontinence

Laparoscopic Burch colposuspension has rapidly become one of the primary surgical treatment options for genuine stress incontinence. The procedure has been modified by some investigators because of technical difficulty with laparoscopic suturing, but should be identical to the conventional open Burch procedure. This article reviews the indications, operative technique, clinical results, complications and learning curve for laparoscopic retropubic surgical procedures.     

Estimation of physiologic ability and surgical stress (E-PASS) as a new prediction scoring system for postoperative morbidity and mortality following elective gastrointestinal surgery

(Received for publication on Oct. 25, 1997; accepted on July 7, 1998)     

Effects of intraoperative glucose administration on circulating metabolites and nitrogen balance during prolonged surgery

Study Objectives: To compare the effects of intraoperative administration of 2.5% glucose or Ringer’s solution on metabolism during prolonged surgery.

Design: Prospective, randomized study.

Setting: Teaching hospital.

Patients: 20 ASA physical status I and II adults patients scheduled for thoracic or abdominal surgery lasting at least 3 hours.

Interventions: Patients received Ringer’s solution (Group R) or 2.5% glucose solution (Group G) 10 ml · kg⁻¹ · h⁻¹ during surgery and 2 ml · kg.⁻¹ · h⁻¹ during the first two postoperative hours (Ringer’s or glucose), then 40 ml · kg.⁻¹ · day⁻¹ of 5% intravenous (IV) glucose postoperatively.

Measurements and Main Results: Plasma glucose, free fatty acids, ketone bodies, lactate, insulin, glucagon, cortisol, and growth hormone concentrations were determined after an overnight fast (T₀), on induction of anesthesia (T₁), at the end of surgery (T₂), 2 hours thereafter (T₃), and on the following morning (T₄). Capillary blood glucose was determined every 30 minutes from T₁ to T₂. Urinary nitrogen and 3-methylhistidine were measured every day for 5 days. There were no differences between groups in demographic data, anesthesia, or surgical procedures. All data were comparable at baseline and on the following morning. In Group R, no patient experienced hypoglycemia, but plasma fatty acids and ketone bodies increased during surgery. In Group G, glycemia rose to very high levels, with a significant increase in insulin during surgery. Other hormones were the same within the two groups. Urinary nitrogen and 3-methylhistidine were similar in both groups.

Conclusion: The absence of glucose infusion in prolonged surgery did not cause hypoglycemia, and no increase in protein catabolism was observed.     

Vertical Banded Gastroplasty-Gastric Bypass with and without the Interposition of Jejunum: Preliminary Report

Background: The complications of the gastric pouch in gastric bypass surgery are well known. Since the first report of this surgery 30 years ago, new technical aspects that make it safer and more effective have been implemented. Methods: As a modification of gastric bypass, the authors have performed 305 vertical banded gastroplasty-gastric bypass procedures. Two groups of patients underwent the procedure: Group I (n = 206) without a limb of jejunum interposed between the gastric pouch and the excluded stomach, and Group II (n = 99) with a limb of jejunum interposed between the pouch and the stomach. The results regarding excess weight loss and complications of the gastric pouch during the first year after surgery were compared. Results: Age, sex, initial weight, body mass index, and percentage of ideal weight were similar in both groups. Excess weight loss was also similar. The complications in Group I were 1 leak, 3 left subphrenic abscesses, 2 erosive gastritis with bleeding, 1 stenosis of the gastrojejunostomy, 1 perforated ulcer, and 4 marginal ulcers with bleeding. Two patients in Group II developed bleeding from the staple-line. Conclusions: These preliminary data suggest that complications of the gastric pouch can be reduced by interposing a limb of jejunum between the pouch and the excluded stomach. This is an early experience; long-term results are pending.     

Patient Satisfaction and Results of Vertical Banded Gastroplasty and Gastric Bypass

Background: Morbid obesity contributes to many health risks, including physical, emotional, and social problems. Various surgical treatments for morbid obesity have developed and have so far met with good results. This study compares vertical banded gastroplasty (VBG) with gastric bypass (GBP) and the patients' satisfaction with either procedure. Methods: Between April 1993 and July 1997, 63 bariatric surgical procedures were performed at Eisenhower Army Medical Center. Of those, complete follow-up was obtained for 29 patients. The parameters evaluated included age, preoperative and postoperative weights, body mass index (BMI), type of surgery, complications, and the patient's level of satisfaction. Results: The study group consisted of 27 women and 2 men. The average preoperative weight was 135 kg, and the average preoperative BMI was 48.3 kg/m². There were 17 VBGs and 12 GBPs performed. The average total weight loss was 45.1 kg. The average postoperative BMI was 33.2 kg/m². There were no statistically significant differences in weight loss between VBG and GBP. Four of 17 patients had complications after VBG, and three of 12 patients had complications after GBP. After VBG, 94.1% of patients were satisfied, and after GBP, 100% were satisfied. Twenty-seven of 28 patients stated that they would have the surgery again. Conclusion: There were no statistically significant differences in weight loss or complications after VBG or GBP. Patient satisfaction was high after both procedures. Therefore, bariatric surgery is important in the treatment of appropriately selected, morbidly obese patients.     

Success Habits of Long-Term Gastric Bypass Patients

Background: By identifying common habits of the most successful long-term gastric bypass patients, one is able to establish more specific guidelines for new patients to follow. The first postoperative year is a critical time that must be dedicated to changing old behavior and forming new, lifelong habits. Methods: 100 gastric bypass patients from 1979 to 1995 participated in a comprehensive survey. Surveys were completed in person, by phone, or in writing. Participants were asked to answer questions regarding their eating, drinking, sleeping, exercise, and personal habits. Results: The survey revealed that specific habits are common in gastric bypass patients who have maintained their weight loss for many years. Conclusion: Identifying and defining the common habits of patients who are successful with long-term weight loss enabled specific guidelines to be established for new patients to implement during the initial weight loss phase, which will contribute to life-long success.