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Andrew A Gumbs

Publications and source records attributed to Andrew A Gumbs.

13 recordsLinked to original sources
PubMed2006

Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Gastrogastric fistula (GGF) secondary to marginal ulceration (MU) is a reported complication of open Roux-en-Y gastric bypass; however, its frequency after laparoscopic gastric bypass (LGBP) is likely underreported. We present five cases of GGF and detail the management algorithm, including medical, endoscopic, and laparoscopic interventions. METHODS: Data from 282 patients undergoing LGBP from October 2002 to January 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with GGF were analyzed. Patients who developed GGF were compared with those who did not using Student's t-test. RESULTS: Five patients (1.8%) subsequently developed GGF. Upper gastrointestinal radiographic evaluation documented the presence of a GGF in these patients, and upper endoscopy confirmed the diagnosis of MU. The mean interval between initial LGBP and subsequent diagnosis of GGF was 8.8 months. Patients who developed GGF were significantly younger (32.4 years vs 41.2 years; P = .007) and had lost significantly more weight 1 year after surgery (82.7% excess weight loss vs 70.0% excess weight loss; P = .003). No difference was noted when comparing operative time (164 minutes vs 148 minutes) or preoperative BMI (45.6 kg/m2 vs 51.4 kg/m2). All MU/GGF patients were treated initially with high-dose proton pump inhibitor (PPI) therapy. In one patient, the GGF closed with PPI therapy alone. A second patient's GGF was successfully resolved with PPI therapy plus endoscopic injection of fibrin sealant. The remaining three cases were managed with laparoscopic division of the fistula after initial unsuccessful PPI therapy. In these patients, the GGF was of larger diameter than in those patients whose GGF closed with medical therapy alone. CONCLUSIONS: MU/GGF should be considered in the differential diagnosis of all postoperative gastric bypass patients who present with abdominal pain. In our series, GGF was always associated with MU. Early diagnosis of GGF can be successfully treated with PPI therapy. Smaller-diameter tracts that do not resolve with medical therapy may respond to endoscopic therapy. Large-caliber fistula are less likely to respond to medical or endoscopic therapy but can be managed laparoscopically.

Abdominal Pain↗
PubMed2006

Laparoscopic adrenalectomy.

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Adenoma↗
PubMed2006

Jejunojejunal anastomotic obstruction following laparoscopic Roux-en-Y gastric bypass due to non-absorbable suture: a report of seven cases.

INTRODUCTION: Small bowel obstruction (SBO) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). We describe 7 cases of jejunojejunal anastomotic obstruction related to adhesion formation after closure of the mesenteric "leaves" defect with non-absorbable suture. METHODS: All patients undergoing LRYGBP from October 2002 until February 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with SBO were analyzed. RESULTS: Jejunojejunal anastomotic obstruction occurred in 7 out of 152 patients (4.6%) in whom LRYGBP was performed from October 2002 to February 2004. Since February 2004, the suture used to close the jejunojejunal mesenteric leaves defect was changed from non-absorbable Dacron (Surgidac) to absorbable suture material. The mean interval between initial LRYGBP and subsequent SBO was 153 days. Operative findings common to all 7 cases were dilated loops of proximal small bowel, and a single adhesion just distal to the Roux-Y anastomosis. Following adhesiolysis, each patient had prompt return of bowel function without recurrence of obstruction. Of the 156 patients who have since undergone LRYGBP, none have presented with SBO, and this difference is statistically significant (P=0.008). CONCLUSIONS: The overall rate of SBO (2.3%) is consistent with the previous literature, although the incidence of adhesions specifically at the jejunojejunal anastomosis is higher than that previously encountered. It appears that the incidence of postoperative SBO at the jejunojejunal anastomosis is directly linked to the choice of suture material intraoperatively. As such, absorbable suture should be used to close the jejunojejunal mesenteric leaves defect.

Adult↗
PubMed2005

Autoimmune pancreatitis presenting as simultaneous masses in the pancreatic head and gallbladder.

CONTEXT: Autoimmune pancreatitis is a rare variant of chronic pancreatitis characterized by pancreatic ductal narrowing and pancreatic parenchymal edema on computed tomography and rarely with intermittent attacks of abdominal pain. Recently, it has been found to be a systemic disease with lymphoplasmacytic infiltration that has been associated with several autoimmune diseases and described in multiple organs including the extrahepatic bile duct, liver and gallbladder. CASE REPORT: We describe the clinical, radiographic and histopathologic aspects of a patient who presented with synchronous masses in the pancreatic head and gallbladder. Postoperatively, the patient's jaundice subsided and IgG4 levels, which were drawn one week postoperatively, were all within normal limits. Nonetheless, immunohistochemical staining for IgG4 was positive. CONCLUSION: Autoimmune pancreatitis is the most common benign entity identified in patients that underwent pancreaticoduodenectomy for presumed pancreatic adenocarcinoma. Our patient with autoimmune pancreatitis presented with simultaneous inflammatory masses in the gallbladder and pancreatic head, an association not previously reported. Preoperative evaluation of IgG4 or autoantibody levels may have obviated the need for an operation. Therefore, we have begun screening for elevated serum IgG4 concentrations to identify patients with possible autoimmune pancreatitis who present without definitive pathological or radiographic evidence for malignancy. If pre-operative diagnosis is not made, immunohistochemical staining of pathology specimens can confirm the diagnosis.

Acute Disease↗
PubMed2005

The open anterior paramedian retroperitoneal approach for spine procedures.

HYPOTHESIS: With the advent of anterior lumbar interbody fusion and artificial disk replacement as common procedures for the treatment of many spinal problems, anterior exposure has become an increasingly popular procedure for general, thoracic, urologic, and vascular surgeons. Despite this, the body of literature describing this procedure, especially the general and vascular surgery literature, is lacking. DESIGN: A retrospective review of medical records was performed for patients operated on from April 2002 to March 2004. SETTING: Tertiary care university hospital. PATIENTS: In total, 64 open retroperitoneal exposures for anterior spinal approaches were performed. Thirty-five (55%) were performed on men and 29 (45%) on women. INTERVENTIONS: Fifty patients (78%) required lumbosacral approaches, and 14 (22%) required access to purely lumbar disk spaces. Forty-three patients underwent single-disk approaches, and 21 required access to either 2 or 3 levels. Forty patients (63%) underwent anterior lumbar interbody fusion, and 22 (34%) had a Prodisc disk replacement. MAIN OUTCOME MEASURES: We analyzed intraoperative and early postoperative complications. RESULTS: The average age was 43 years (range, 25-89 years), 42 and 44 years for men and women, respectively. Ninety-seven percent of all attempted retroperitoneal exposures were successful. Intraoperative complications occurred in 5 patients (8%) and included inability to mobilize the iliac veins, injury to the iliac vein, and ureteral tear. The postoperative course was complicated in 8 patients (14%) and included fever, urinary retention, spinal headache, Clostridium difficile colitis, and ileus. CONCLUSION: Open retroperitoneal exposure to the lumbar and lumbosacral vertebral bodies can be performed safely with a multidisciplinary approach that maximizes the various surgical skills of the orthopedic and vascular or general surgeon, reducing complication rates in anterior spinal surgery.

Adult↗
PubMed2005

Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss.

The prevalence of type 2 diabetes mellitus (T2DM) and obesity in the western world is steadily increasing. Bariatric surgery is an effective treatment of T2DM in obese patients. The mechanism by which weight loss surgery improves glucose metabolism and insulin resistance remains controversial. In this review, we propose that two mechanisms participate in the improvement of glucose metabolism and insulin resistance observed following weight loss and bariatric surgery: caloric restriction and weight loss. Nutrients modulate insulin secretion through the entero-insular axis. Fat mass participates in glucose metabolism through the release of adipocytokines. T2DM improves after restrictive and bypass procedures, and combinations of restrictive and bypass procedures in morbidly obese patients. Restrictive procedures decrease caloric and nutrient intake, decreasing the stimulation of the entero-insular axis. Gastric bypass (GBP) operations may also affect the entero-insular axis by diverting nutrients away from the proximal GI tract and delivering incompletely digested nutrients to the distal GI tract. GBP and biliopancreatic diversion combine both restrictive and bypass mechanisms. All procedures lead to weight loss and decrease in the fat mass. Decrease in fat mass significantly affects circulating levels of adipocytokines, which favorably impact insulin resistance. The data reviewed here suggest that all forms of weight loss surgery lead to caloric restriction, weight loss, decrease in fat mass and improvement in T2DM. This suggests that improvements in glucose metabolism and insulin resistance following bariatric surgery result in the short-term from decreased stimulation of the entero-insular axis by decreased caloric intake and in the long-term by decreased fat mass and resulting changes in release of adipocytokines. Observed changes in glucose metabolism and insulin resistance following bariatric surgery do not require the posit of novel regulatory mechanisms.

Biomarkers↗
PubMed2004

Migratory necrolytic dermatitis presenting after cephalosporin administration in a patient with a pancreatic head mass.

Migratory necrotizing dermatitis is one of the most distressing presenting symptoms of glucagonomas. This rare functioning pancreatic endocrine tumor is third in incidence after insulinomas and gastrinomas and is often malignant at the time of diagnosis. Elevated serum glucagon levels cause decreased amino acid levels which is believed to be the principal cause of the dermatitis. Other symptoms include anemia, visual scotomata and mild diabetes mellitus. Medical treatment alone including octreotide and amino acid supplementation has been reported to eliminate the dermatitis. Nonetheless, surgical resection or debulking remains the definitive treatment when possible. Because of its rarity, diagnosis may be delayed by years accounting for the high rate of metastasis at presentation. Reported here is the case of a 77-year-old man who presented with a migratory necrotizing dermatitis after antibiotic treatment and whose diagnosis of a glucagonoma was then delayed for over 1 year.

Aged↗
PubMed2003

Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial.

BACKGROUND: Anastomotic failure is still a significant problem that affects the outcome of pancreaticoduodenectomy. There have been many techniques proposed for the reconstruction of pancreatic digestive continuity, but there have been few prospective and randomized studies that compare their efficacy. METHODS: In the current work, 144 patients who underwent a pancreaticoduodenectomy with soft residual tissue were assigned randomly to receive either a duct-to-mucosa anastomosis (group A) or a 1-layer end-to-side pancreaticojejunostomy (group B). RESULTS: The 2 treatment groups were found not to have any differences in regards to vital statistics, underlying disease, or operative techniques. The postoperative course was complicated in 54% of the 144 patients, with a comprehensive incidence of abdominal complications in 36% (group A, 35%; group B, 38%; P=not significant). The principal complication was pancreatic fistulas, which occurred in 14% of patients (group A, 13%; group B, 15%; P=not significant). Two patients (2%) required reoperation; the postoperative mortality rate was 1%. CONCLUSION: The 2 methods that were studied revealed no significant difference the rate of complications.

Adult↗
PubMed2002

The value of standard serum tumor markers in differentiating mucinous from serous cystic tumors of the pancreas: CEA, Ca 19-9, Ca 125, Ca 15-3.

BACKGROUND: Differentiating between mucinous cystic tumors (MCTs) and serous cystic tumors (SCTs) can be a troubling diagnostic dilemma in pancreatology: when SCTs present in their macro-oligocystic form they must be resected because MCT cannot be ruled out, and some tumors considered benign are actually MCTs, which delays diagnosis and places patients at increased risk. Examination of preoperative serum tumor markers may help improve preoperative diagnosis. MATERIALS AND METHODS: The tumor markers CEA, Ca 19-9, Ca 125, and Ca 15-3 were examined in 157 patients with SCTs or MCTs. RESULTS: Positive CEA marker status is an indicator of an MCT, although sensitivity is low at 17%. Using three serum tumor markers (CEA, Ca 19-9, and Ca 125), 27% of MCTs were found to have two or more markers positive, compared to none for the SCTs. Sensitivity decreases to 13% for differentiating benign MCTs from benign SCTs but specificity remains 100%. CONCLUSIONS: In the differential diagnosis of SCTs vs. MCTs no reliable serum tumor marker exists which can diagnose SCTs and spare some patients unnecessary operations. Nonetheless, positive CEA serum marker status and or the presence of more than two positive serum markers (CEA, Ca 19-9, or Ca 125) indicates the presence of an MCT and can prevent delay in diagnosis.

Adult↗
PubMed2002

Overexpression of the Sm-like proto-oncogene in primary and metastatic pancreatic endocrine tumors.

CONTEXT: The cancer associated Sm-like proto-oncogene mRNA has been found to be overexpressed in the majority of pancreatic adenocarcinomas and is necessary for the transformed phenotype in pancreatic cancer cell lines. However, expression levels have not been examined in other types of pancreatic neoplasms, such as pancreatic endocrine tumors. SETTING: Fifteen primary pancreatic endocrine tumors, including five insulinomas and 10 non-functioning tumors, along with seven hepatic metastatic pancreatic endocrine tumors. MAIN OUTCOME MEASURES: Quantitative expression levels of cancer associated Sm-like mRNA were measured by real-time PCR. Overexpression was defined as a two-fold or greater value when compared to the expression levels found in normal pancreatic islet cells obtained from healthy donors. RESULTS: In primary tumors, four of the 10 non-functioning pancreatic endocrine tumors were found to overexpress cancer associated Sm-like mRNA (40%). Three of the five (60%) insulinomas also overexpressed cancer associated Sm-like mRNA. In total, cancer associated Sm-like mRNA was overexpressed in seven of 15 primary tumors (47%) and in the majority (71%, 5 of 7) of the hepatic metastases. CONCLUSIONS: Our results indicate that the cancer associated Sm-like mRNA gene may also play a role in the tumorigenesis of pancreatic endocrine tumors.

Adenoma, Islet Cell↗
PubMedDate not supplied

Treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysms: transcaval approach.

The purpose of the note is to describe a new technique for type II endoleak treatment, using an alternative approach through femoral venous access. Three patients who developed type II endoleak after endovascular repair of abdominal aortic aneurysm were treated with direct transcaval puncture and embolization inside the aneurysm sac. The detailed technique is described. All patients were treated without any complications and discharged 48 hours after the treatment. At 1 month follow-up the computed tomograph scan did not show a recurrence of a type II endoleak. The management of patients with type II endoleak is a controversial issue and different techniques have been proposed. We suggest an alternative technique for type II endoleak treatment. The feasibility and the advantages of this approach can offer new possibilities for the diagnosis as well as for the treatment of this complication.

Aortic Aneurysm, Abdominal↗
PubMedDate not supplied

Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass.

BACKGROUND: Marginal ulceration (MU) is a well-known complication after gastrojejunostomy; however, its incidence has rarely been reported in bariatric studies. We present 16 cases of documented MU after laparoscopic gastric bypass (LGBP) that were successfully treated with proton pump inhibition (PPI). METHODS: All patients undergoing LGBP from October 2002 to August 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with MU were analyzed. MU was diagnosed when patients presented postoperatively with mid-epigastric pain and/or upper gastrointestinal bleeding that responded to PPI or endoscopic intervention. Analysis of variance and Student's t test were used for the statistical analyses. RESULTS: MU was diagnosed in 16 (4%) of 347 patients in whom LGBP was performed. An additional 10 patients had symptoms suggestive of MU, which raised the incidence as great as 7%. Of the 26 patients, 18 were women and 8 were men (age range 23-53 years), with a preoperative body mass index 37.1-63.9 kg/m2, similar to that of the patients who did not develop MU. Compared with the patients who did not develop MU, the operative times were longer in the MU group (180.5 versus 140.4 minutes, P <0.001). Of the 26 patients, 10 presented with abdominal pain and 16 with upper gastrointestinal bleeding. The mean interval between the initial LGBP and subsequent MU was 6.3 months (range 1-13). After an initial history and physical examination, upper endoscopy confirmed the diagnosis of MU in 16 patients. Three patients who developed MU were receiving chronic anticoagulation medication. All patients who developed MU began high-dose PPI, which resulted in 100% resolution of MU within 8 weeks. Since January 2005, 73 patients were given prophylactic PPI therapy postoperatively, with no patients subsequently developing MU (P = 0.006). CONCLUSION: We report 16 documented cases of MU occurring after LGBP. This underreported complication can be successfully treated with PPI, although MU complicated by gastrogastric fistula may require operative intervention. The institution of routine PPI therapy after LGBP lowered the short-term incidence of MU at our institution. Additionally, we recommend that all patients who undergo LGBP be given prophylactic PPI therapy postoperatively.

Adult↗