Faculty Bibliography

Aims: Local ablative therapies, such as radiofrequency ablation (RFA) and microwave ablation (MWA), are commonly used to treat patients with unrespectable or recurrent hepatocellular carcinoma (HCC). These therapies are generally safe and well tolerated, yet complications related to mechanical or thermal damage may result. This case highlights a very rare complication after local ablative therapy for HCC, namely diaphragmatic perforation, and demonstrates a step-by-step laparoscopic repair. Methods: This is the case of an 81-year-old female with segment 4B hepatocellular carcinoma diagnosed in 2008, treated with laparoscopic radiofrequency ablation. The disease recurred in 2012 and subsequent microwave ablation and trans-arterial chemoembolization were performed. One year later, the patient developed severe right upper quadrant abdominal pain. CT scan showed incarcerated colon and cecum herniating through the right diaphragm with associated colonic obstruction. The patient was taken to the OR for laparoscopic repair of the diaphragm and possible bowel resection. With the patient in the right lateral decubitus position, the terminal ileum, cecum, and right colon were reduced and the diaphragm repaired with 0-prolene sutures in a horizontal mattress fashion. A 34 French chest tube was placed. Upon further inspection, the right colon appeared gangrenous. The patient was then repositioned into the supine position and a laparoscopic right hemicolectomy was performed. Results: The patient was extubated on postoperative day 1. Recovery was complicated by a subdiaphragmatic abscess, which responded to percutaneous drainage and antibiotics. The patient was subsequently discharged to a subacute rehab facility. Conclusion: With only a few cases cited in the literature, diaphragmatic perforation is an uncommon complication of local ablative therapies for HCC. The mechanism of injury is presumably thermal injury to the diaphragm. In cases of acute right upper quadrant abdominal pain after RFA or MWA, this rare but serious complication should remain in the differential

Marginal Ulcers (MU) are the most common cause of bleeding after RYGB. Surgical management is required if endoscopic treatment fails to control the bleeding. In this video, we present the case of a laparoscopic repair of an actively bleeding marginal ulcer after RYGB. The repair was performed via a jejunal enterotomy with meticulous ligation of bleeding vessels, and did not require revision of the gastrojejunal anastomosis

Laparoscopic sleeve gastrectomy (LSG) is rapidly becoming one of the most commonly performed bariatric surgical procedures. With the increase in frequency of this procedure, surgeons should be knowledgeable about its complications and anesthesiologists need to be familiar with the intraoperative technique. This video presents the case of an intraoperative transection of an orogastric tube during LSG, and its subsequent operative and postoperative management

BACKGROUND: Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG). METHODS: We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission. RESULTS: Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) >/=3 days (OR 2.54, CI = [1.19, 5.40]), intraoperative drain placement (OR 3.11, CI = [1.58, 6.13]), postoperative complications (OR 8.21, CI = [2.33, 28.97]), and pain at discharge (OR 8.49, CI = [2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR 72.4, CI = [15.8, 330.5]). CONCLUSIONS: The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

RATIONALE: Obesity is characterized by increased systemic and pulmonary blood volumes (pulmonary vascular congestion). Concomitant abnormal alveolar membrane diffusion suggests subclinical interstitial edema. In this setting, functional abnormalities should encompass the entire distal lung including the airways. OBJECTIVES: We hypothesize that in obesity: 1) pulmonary vascular congestion will affect the distal lung unit with concordant alveolar membrane and distal airway abnormalities; and 2) the degree of pulmonary congestion and membrane dysfunction will relate to the cardiac response. METHODS: 54 non-smoking obese subjects underwent spirometry, impulse oscillometry (IOS), diffusion capacity (DLCO) with partition into membrane diffusion (DM) and capillary blood volume (VC), and cardiac MRI (n = 24). Alveolar-capillary membrane efficiency was assessed by calculation of DM/VC. MEASUREMENTS AND MAIN RESULTS: Mean age was 45+/-12 years; mean BMI was 44.8+/-7 kg/m2. Vital capacity was 88+/-13% predicted with reduction in functional residual capacity (58+/-12% predicted). Despite normal DLCO (98+/-18% predicted), VC was elevated (135+/-31% predicted) while DM averaged 94+/-22% predicted. DM/VC varied from 0.4 to 1.4 with high values reflecting recruitment of alveolar membrane and low values indicating alveolar membrane dysfunction. The most abnormal IOS (R5 and X5) occurred in subjects with lowest DM/VC (r2 = 0.31, p<0.001; r2 = 0.34, p<0.001). Cardiac output and index (cardiac output / body surface area) were directly related to DM/VC (r2 = 0.41, p<0.001; r2 = 0.19, p = 0.03). Subjects with lower DM/VC demonstrated a cardiac output that remained in the normal range despite presence of obesity. CONCLUSIONS: Global dysfunction of the distal lung (alveolar membrane and distal airway) is associated with pulmonary vascular congestion and failure to achieve the high output state of obesity. Pulmonary vascular congestion and consequent fluid transudation and/or alterations in the structure of the alveolar capillary membrane may be considered often unrecognized causes of airway dysfunction in obesity.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric surgical procedure in the US. It is considered technically simpler to perform than the gastric bypass and is more effective than the gastric band. It is an ideal procedure to implement in an urban safety-net hospital with limited resources. There is also debate regarding "Center of Excellence (COE)" accreditation and potential decreased access to bariatric surgery for under-represented minorities. Methods: A retrospective chart review of the first 1000 LSG at our institution was performed. Our institution is a public hospital that primarily serves under-represented minorities. Patient demographics and surgical outcomes were collected. A repeated measures model was used to create a % excess weight loss (%EWL) model. Outcomes were also compared before vs. after COE accreditation. Results: The cohort was predominantly Hispanic and non-Hispanic African American (96%). The vast majority (>75%) were insured publicly or were uninsured (15%). Mean age and BMI were 39 years and 45 kg/m2, respectively. There was an eleven-fold increase in surgical volume after COE accreditation. 1 year %EWL was 64%. 30-day readmission and reoperation was 1.5% and 0.4%, respectively. Leak rate was 1.2%. There were no mortalities. Conclusions: The COE model facilitated safe expansion of LSG at an urban safety-net institution

Intro: Laparoscopic adjustable gastric banding is well-known for its safety profile. However, band removal, especially for a device-related complication, may be more complex due to the scar tissue created by the band. The objective of this study is to review perioperative outcomes of patients requiring band removal for device-related complications. Methods: A retrospective review was conducted of all band removals over a 13 year period (2001-2014) for a device-related complication (e.g. slippage, erosion, gastric necrosis). Bands removed for weight loss failure or intolerance were excluded from this review. Perioperative complication, readmission and reoperation/re-intervention was defined according to the Metabolicand Bariatric Surgery Accreditation and Quality Improvement Program standards. Results: A total of 104 patients required band removal for a device-related complication. In the same time frame 7633 bands were implanted. The average age at band removal was 44 years old and the average BMI was 35.6. The most common reason was slip (42%) and erosion (28%). The 30-day complication rate from the removal was 26% (27/104) - most commonly pneumonia and perigastric abscess. The 30-day readmission rate and reoperation/ re-intervention rate were 15% and 10%, respectively. There was one mortality (1%) from septic shock secondary to erosion. There were no statistically significant differences in age (p = 0.452) or BMI (p = 0.523) between those who had a 30-daycomplication and those who did not. Conclusions: Band-related complications are rare. Band removal for device-related complication may be associated with significant morbidity

Background: At our medical center, female patients who have undergone bariatric surgery are advised to defer pregnancy for two years surgery, in an attempt to avoid the following complications: inadequate maternal weight gain (for pregnancy), inadequate maternal weight loss (following bariatric surgery), hyperemesis gravidarum, and nutritional deficiencies. Methods: We examined our database of bariatric surgery patients from a large, urban, public hospital from March 2011 to July 2013. During that period, we identified 54 women who became pregnant after undergoing bariatric surgery. Of these women, 41 were included in the analysis. Twenty-six pregnancies occurred in women who had undergone bariatric surgery less than 2 years prior to conception, and 15 occurred in women who had undergone bariatric surgery greater than 2 years prior to conception. Gestational age at delivery, number of NICU admissions, weight gain during pregnancy, hyperemesis gravidarum, and nutritional deficiencies (iron, vitamins, protein, glucose) during pregnancy were compared for the two groups. Results: The women with <2 years between bariatric surgery and conception had a higher percentage of RYGB and LSG surgeries (p=0.0003), and had more weight loss (p=0.018) and BMI loss (0.014) from bariatric surgery to conception. There were no significant differences in pregnancy outcomes when comparing mothers with <2 years and >2 years between bariatric surgery and conception. The rates of full-term deliveries (85% vs. 87%, P=0.321), NICU admissions (4% vs. 7%, P=0.999), hyperemesis gravidarum (31% s. 40%, P=0.548) were not significantly different between the two groups. There were also no significant differences in nutritional deficiences, including iron (58% vs. 60%, P=0.885), vitamin B1(46% vs. 20%, P=0.177), vitamin B6 (12% vs. 0%, P=0.287), vitamin B12 (31% vs. 13%, P=0.277) vitamin D (65% vs. 87%, P=0.168), protein (62% vs. 40%, P=0.183) and low blood glucose (77% vs. 73%, P=0.999). Conclusions: There were no significant differences in gestational age, rate of NICU admission, pregnancy weight gain, hyperemesis, or nutritional deficiencies when comparing women who conceived within 2 years or after 2 years of their bariatric surgery. (Table Presented)