Faculty Bibliography

BACKGROUND:Although it is generally accepted that closure of mesenteric defects after laparoscopic Roux-en-Y gastric bypass (LRYGB) reduces the incidence of small bowel obstruction (SBO), data supporting this belief are inconsistent. After a spike in acute SBO cases in our LRYGB patients, we changed our technique of mesenteric closure. The objective of this study was to determine whether modification of our technique of mesenteric closure would decrease the incidence of SBO and internal hernia after LRYGB. METHODS:The records of 872 consecutive patients who had antecolic LRYGB by 1 surgeon over a 9-year interval were reviewed for acute SBO. The first 654 patients, mean follow up = 100±12 months, had incomplete mesenteric closure versus complete closure in 218 remaining patients, mean follow up = 40±14 months. Minimum follow up was 1 year. RESULTS:Total incidence of acute SBO was 4.0% (35/872), including 4.4% (29/654) in the incomplete closure group versus 2.8% (6/218) in the complete closure patients. Seventeen (2.6%) of the incomplete closure patients with acute SBO had internal hernias versus 1 (.5%) in the complete closure group. Twenty-six patients with incomplete closure developed symptoms of SBO and subsequently had elective repair of mesenteric hernias versus none in complete closure group (P<.02). Postoperative morbidity and mortality rates after surgery for SBO were 30% and 7.4% in incomplete group versus zero in patients with complete closure. CONCLUSION/CONCLUSIONS:Complete closure of mesenteric defects in antecolic LRYGB resulted in a significant reduction in internal mesenteric hernias. Complications were also reduced after operations for SBO in patients who had complete mesenteric closure.

Prompt appendectomy has always been a standard of care because of the risk of progression in pathology. This time honored practice has been recently challenged by studies, suggesting that appendicitis can be operated on electively. The aim of this study is to examine whether delayed intervention in acute appendicitis is safe by correlating the interval from presentation to operation with the operative and postoperative complications. Retrospective review of patients who underwent appendectomy for acute appendicitis in 2009 was done. The following parameters were recorded: demographics, duration from presentation to evaluation by emergency room attending, performing CT scan, surgical consult, and operation. The pathology, post operative complications, and length of stay were also recorded. Patients were divided into two groups: incision time < 10 hours (early group) and incision time > 10 hours (delayed group). The end points chosen for comparison were: 1) laparoscopic to open conversion rate, 2) complications, 3) readmissions, and 4) length of stay. Number of cases totaled 201, with 76 in the < 10 hours group and 125 in the > 10 hours group. The male to female ratio for the < 10 hours group was 54:22 and for the > 10 hours group was 59:66 (P < 0.001). Length of stay for the early group was 75.52 hours and for the delayed group, 89.15 hours (P = 0.04). There was one intra-abdominal abscess in the early group and 10 in the delayed group (P = 0.04). The early group had 0.2 (2.6%) open conversions, and the delayed group had five (4.1%) conversions (P = 0.58). There were six (4.8%) readmissions in the delayed group and none in the early group (P = 0.05). Our study reveals that the complication rate, length of stay, and readmissions are more in the delayed group. Conversion rate was more in the delayed group, but the difference was not significant. We conclude that early surgical intervention is beneficial in acute appendicitis.

INTRODUCTION/BACKGROUND:The duodenum is the second most common site for diverticulae, after the colon. They are common after the fifth decade and usually asymptomatic. Ten percent of patients present with symptoms, which include abdominal pain, hemorrhage, duodenal obstruction, diverticulitis, perforation, pancreatitis, and obstructive jaundice. After a thorough search of medline we present, for the first time, a case of obstructive jaundice secondary to duodenal diverticulum compressing the common bile duct. It was managed by laparobotic duodenal diverticulectomy with choledocho-duodenostomy. The operative technique is discussed. CASE STUDY/METHODS:A 78-year-old female was found to have an abnormal cholestatic liver function profile and dilated common bile duct during workup for upper abdominal pain. CT scan showed dilated common bile duct measuring 2.7 cm with suspected ampullary mass. Endoscopic ultrasound showed a large diverticulum next to the ampulla. Upper GI endoscopy confirmed duodenal diverticulum, arising from the second part of the duodenum. Laparobotic duodenal diverticulectomy and choledochoduodenostomy were performed. Her post-operative course was complicated by Clostridium difficile diarrhea, treated with metronidazole and she was discharged home on the 6th postoperative day. Follow-up at 18 months demonstrated that she was well. CONCLUSION/CONCLUSIONS:Obstructive jaundice due to compression by a duodenal diverticulum is rare. It poses a diagnostic challenge and requires technically demanding surgical and endoscopic intervention. Robotic surgery has revolutionized the field of minimally invasive surgery by improving vision and motion control. Robotic duodenal diverticulectomy and choledocho-duodenostomy are safe and feasible.

BACKGROUND:Mantle cell lymphoma (MCL) is an aggressive type of B-cell non-Hodgkin's lymphoma that originates from small to medium sized lymphocytes located in the mantle zone of the lymph node. Extra nodal involvement is present in the majority of cases, with a peculiar tendency to invade the gastro-intestinal tract in the form of multiple lymphomatous polyposis. MCL can be accurately diagnosed with the use of the highly specific marker Cyclin D1. Few cases of mantle cell lymphoma presenting with intussuception have been reported. Here we present a rare case of multiple intussusceptions caused by mantle cell lymphoma and review the literature of this disease. CASE PRESENTATION/METHODS:A 68-year-old male presented with pain, tenderness in the right lower abdomen, associated with nausea and non-bilious vomiting. CT scan of abdomen revealed ileo-colic intussusception. Laparoscopy confirmed multiple intussusceptions involving ileo-colic and ileo-ileal segments of gastrointestinal tract. A laparoscopically assisted right hemicolectomy and extended ileal resection was performed. Postoperative recovery was uneventful. The histology and immuno-histochemistry of the excised small and large bowel revealed mantle cell lymphoma with multiple lymphomatous polyposis and positivity to Cyclin D1 marker. The patient was successfully treated with Rituximab-CHOP chemotherapy and remains in complete remission at one-year follow-up. CONCLUSION/CONCLUSIONS:This is a rare case of intestinal lymphomatous polyposis due to mantle cell lymphoma presenting with multiple small bowel intussusceptions. Our case highlights laparoscopic-assisted bowel resection as a potential and feasible option in the multi-disciplinary treatment of mantle cell lymphoma.