Faculty Bibliography

BACKGROUND:Bleeding in the early postoperative period after gastric bypass surgery is a rare complication reported in 1-4% of cases. In most cases, the bleeding will be self-limited, resolving after discontinuation of anticoagulation for deep venous thrombosis prophylaxis. Occasionally, however, bleeding can be problematic, resulting in significant postoperative morbidity or even mortality. The purpose of the present study was to review cases of early postoperative gastrointestinal bleeding after gastric bypass to identify possible risk factors and examine outcomes. METHODS:A prospective weight loss surgery patient database was reviewed to examine the cases occurring from January 2005 to July 2008. Patients with early postoperative bleeding were identified. The demographics and co-morbidities were compared between those with and without postoperative bleeding. The outcomes of interest included the transfusion requirement, postoperative morbidity, need for reoperation, length of hospital stay, intensive care unit admission, and 30-day mortality. RESULTS:A total of 776 patients had undergone gastric bypass during the study period. Of these, 26 (3.3%) were identified with early postoperative bleeding. No significant differences were found in the demographics between the patients with early postoperative bleed and those without. Of the patients with early postoperative bleeding, the most common presenting sign or symptom was tachycardia (46%) followed by melena (32%) and hematemesis (18%). The transfusion requirement range was 0-11 U (average 3.2 U/patient). Of the 26 patients, 4 (15%) required intensive care unit admission and 8 (31%) required reoperation. Four gastrointestinal leaks, one stomal ulceration, and one gastrogastric fistula were identified in the early postoperative bleeding group. One patient (3.8%) in the early postoperative bleeding group died. Compared with nonbleeding patients, those with early postoperative bleeding had a significantly longer hospital stay (4.8 versus 3, P <.0001) and greater mortality rate (7.1% versus .9%, P <.01). CONCLUSION/CONCLUSIONS:Postoperative bleeding is a significant complication after gastric bypass surgery. Although in many cases, the bleeding will be self-limited, it can result in additional notable complications. In the present study, postoperative bleeding contributed to significantly longer hospital stays and resulted in 1 death. A patient with bleeding after gastric bypass should raise due concern, with attention to the potential attendant complications.

Cystic lesions of the pancreas are identified with increasing frequency by modern imaging. The mucinous cystic neoplasm (MCN) is treated with resection for its malignant potential. How much preoperative evaluation is needed before undertaking operation is frequently a diagnostic dilemma. A retrospective review of 32 patients who underwent resection of a MCN between 1994 and 2007 was performed to define the preoperative evaluation and operative treatment of MCN patients. Thirty-two patients (30 women; mean age 49) had histology-proven MCN. Twenty-seven patients had symptomatic cysts (84%). Five had a history of gallstones and/or acute pancreatitis. All patients were worked up with CT and/or MRI. Endoscopic ultrasound was performed in 14 (44%) and endoscopic retrograde cholangiopancreatography in six (18%). Cytology was obtained in 13 (40%). Pathology revealed 22 benign MCNs (68%), five malignant MCNs (16%), and five MCNs with borderline pathology. Preoperative workup including CT or MRI imaging and cytology suggested MCN as the lesion in 15 patients (46%). CT features by itself predicted MCN in three patients (9%). Cytology revealed another six patients (19%) with possible MCN. In this series, preoperative workup did not identify three of five patients with MCN malignancy. A preoperative diagnosis cannot be made in most patients with MCN. Operative treatment can be based on clinical presentation and CT imaging because endoscopic ultrasound and fine needle aspiration for evaluation may be misleading. Middle-aged women with cystic lesions in the tail of the pancreas without prior gallstone or pancreatitis history most typically fit the profile of the MCN patient.

Injury to the common bile duct (CBD) during upper gastrointestinal surgery for peptic ulcer disease is a serious complication with an underestimated prevalence in light of the few cases reported in the surgical literature. Three cases of CBD injury were referred to a multidisciplinary specialized gastrointestinal unit for management over a 4-year period. Anomalous anatomy, adhesions, and potential duodenal shortening secondary to contracture all predispose the biliary ducts to intraoperative injury. The axial nature of the blood supply to the extrahepatic ducts and the tendency of bile itself to cause rapid collagen turnover and fibrosis, combined with the inflammation and subsequent fibrosis to the surrounding tissues caused by bile leakage, give the bile ducts a high propensity for stricture formation. Frequently presenting symptoms of CBD injury immediately after surgery include jaundice, elevated bilirubin values, elevated t-tube drainage, and symptoms of sepsis. The most common complaints noted in patients who present in a delayed manner are symptoms of cholangitis. Even when injuries are rapidly identified and corrected, the potential for lasting negative impact on quality of life is great in many cases. When CBD injury occurs, the pancreatic duodenal union can be concomitantly disrupted.

BACKGROUND:Patients who have undergone Roux-en-Y gastric bypass for morbid obesity may develop postoperative abdominal pain disorders that require surgical evaluation. Chronic pancreatitis and pain associated with sphincter of Oddi dysfunction (SOD) is an uncommon disorder whose clinical diagnosis is problematic without sphincter of Oddi manometry. To evaluate the diagnosis and treatment of SOD in the gastric bypass population, a retrospective review and analysis of gastric bypass patients who had undergone transduodenal sphincteroplasty (TS) for SOD was undertaken. METHODS:The medical records of patients who had undergone TS after gastric bypass at the Medical University of South Carolina Digestive Disease Center from January 2002 to December 2006 were evaluated for outcomes-based data with the approval of the institutional review board for the evaluation of human subjects. Long-term patient outcomes were assessed using the Medical Outcomes Study Short Form 36-item, version 2, quality-of-life survey. RESULTS:A total of 16 women (median age 49 years) were identified who had undergone TS with biliary sphincteroplasty and pancreatic ductal septoplasty for SOD. The indications for surgery included pain (100%), nausea (31%), weight loss (13%), and recurrent pancreatitis (31%). The diagnosis of SOD was supported by magnetic resonance cholangiopancreatography with secretin stimulation. Three postoperative complications (18.8%) developed, but no mortality. The average length of hospital stay was 5 days (range 2-9). Of the 16 patients, 13 (81%) responded to the survey follow-up. The mean length of follow-up was 28 months (range 16-57). Of the 13 patients, 11 (85%) reported pain improvement after surgery. The survey's norm-based scores were similar to those of a representative population. CONCLUSION/CONCLUSIONS:SOD should be considered in the differential diagnosis of gastric bypass patients with pancreatobiliary pain after cholecystectomy. When the clinical history is supported by laboratory and magnetic resonance cholangiopancreatography data, TS can be undertaken with low morbidity and good patient outcomes. SOD is a notable disorder in the gastric bypass population. With appropriate patient selection, TS can be beneficial.

Because of poor outcomes with traditional surgical management, total pancreatectomy with autologous islet transplantation (TPAIT) has been heralded as a breakthrough in the management of severe chronic pancreatitis intractable to medical management. To assess the impact of TPAIT on a pancreatobiliary disease-based center, a retrospective review and analysis of patients who underwent TPAIT after failing traditional surgical management was undertaken. Seven patients who underwent TPAIT were identified. Patient hospitalizations, emergency department visits, and clinic visits in the year pre- and post-TPAIT were tabulated. Average body weights and serum prealbumin were recorded during the year pre- and post-TPAIT. Based on the number of hospitalizations, clinic visits, and emergency department visits as an indicator of overall symptom severity, patients experienced an improvement in symptoms during the 12 months after TPAIT. Prealbumin values remained stable during the postoperative year. An observed decrease in weight suggests that other factors may be impacting the overall state of nutrition. The impact of TPAIT on the surgical management of chronic pancreatitis is limited in scope and benefit and continues to require careful analysis to identify appropriate candidates.

BACKGROUND:Surgical management of sphincter of Oddi dysfunction and pancreas divisum is controversial. In the modern era of therapeutic endoscopy, pain persisting despite endoscopic sphincterotomy and anatomy that makes the ampulla endoscopically inaccessible prompt referral for surgical transduodenal sphincteroplasty (TS). A retrospective review of sphincter of Oddi dysfunction and pancreas divisum patients who underwent TS for refractory pain in a recent time period was undertaken. STUDY DESIGN/METHODS:The medical records of all patients who underwent TS for sphincter of Oddi dysfunction and pancreas divisum at the Medical University of South Carolina between January 2001 and December 2005 were reviewed. Longterm outcomes were assessed by a standardized written questionnaire and the SF-36 version 2 Quality of Life Survey. RESULTS:Sixty-eight patients underwent TS (median age 43 years, 54 women). Fifty-one had earlier endoscopic sphincterotomy; 17, with previous gastric surgery, did not. Operative morbidity was 10.3%, with no mortality. Forty-five patients (66%) completed the questionnaire; 62% had improvement in pain, without reintervention, over a median followup of 42.5 months (range 16 to 75 months). There was a trend toward more favorable outcomes in patients with earlier gastric surgery (no previous endoscopic sphincterotomy) compared with others (90% versus 54%, p=0.06). Multivariate analysis showed chronic pancreatitis (odds ratio 0.11 [95% CI 0.02 to 0.68; p=0.02]) and younger age (odds ratio 3.9 [95% CI 1.32 to 11.53; p=0.01] per decade) were independent predictors of poorer outcomes. CONCLUSIONS:Good longterm outcomes with low operative morbidity can be obtained with TS in selected patients, including those with postgastric bypass, but younger age and chronic pancreatitis appear to predict poorer outcomes.