Biomedical subjects

Natan Zundel

Publications and source records attributed to Natan Zundel.

11 recordsLinked to original sources

PubMed2006

Laparoscopic surgery for morbid obesity: 1,001 consecutive bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida.

BACKGROUND: Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. METHODS: A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. RESULTS: 2 surgeons performed 1,001 laparoscopic bariatric operations. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m2, and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. CONCLUSION: Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.

Adult↗

PubMed2005

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure. METHODS: We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery. RESULTS: The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically. CONCLUSION: Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.

Abdominal Pain↗

PubMed2005

Diabetes mellitus-associated diffuse autonomic dysfunction causing debilitating hypotension manifested after rapid weight loss in a morbidly obese patient: case report and review of the literature.

The association between weight and blood pressure is well established, especially the paradigm of obesity-related hypertension. The relationship between diffuse autonomic dysfunction and orthostatic hypotension in patients with long-term diabetes mellitus is also well known. We report on a 57-year-old morbidly obese male with a long medical history of hypertension, myocardial infarction, type 2 diabetes mellitus, and hypothyroidism. After a loss of 147 pounds (representing a percent excess weight loss of 76%) within 6 months after gastric bypass surgery, the patient developed worsening orthostatic hypotension and near-syncopal episodes requiring medication. The subsequent diagnosis and treatment, as well as a literature review, are presented.

Anastomosis, Roux-en-Y↗

PubMed2005

Laparoscopic transhiatal esophagectomy for esophageal cancer.

BACKGROUND: Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications. METHODS: A retrospective analysis of patients who underwent laparoscopic transhiatal esophagectomy was performed. Assessed parameters included patient demographics and operative data, pathology results, and long-term follow-up of at least 12 months. RESULTS: Twenty-two patients underwent laparoscopic transhiatal esophagectomy; 19 had esophageal cancer. Two patients were operated on for Barrett esophagus, and 1 patient had achalasia. The majority of patients were men (82%), and the mean age was 59 years (range 15 to 74 years); 1 patient (4.5%) was converted to open surgery. The average operative time was 380 minutes (range 285 to 525 minutes), and the average blood loss was 220 mL; only 3 patients required transfusion. The median hospital stay was 8 days (range 5 to 46 days). Postoperative mortality occurred in 1 patient (4.5%), and postoperative complications developed in 6 patients (27.2%). In the 19 cancer patients, the average number of harvested nodes was 14.3 (range 10 to 19). The average follow-up was 30 months (range 12 to 48 months). The overall survival for cancer patients was 61% (11 of 19), and disease-free survival was 39% (7/19). CONCLUSIONS: Esophagectomy is a major surgery with considerable morbidity and potential mortality. Minimally invasive esophagectomy is a feasible approach that can be safely performed by surgeons with extensive experience in that field. Advantages include less intraoperative blood loss, a smaller incision, and a potentially faster postoperative recovery. In cancer patients, immediate oncologic goals of adequate margins and lymph node dissection can be achieved, and long-term outcome appears to be similar to that found with open approaches.

Adolescent↗

PubMed2005

Laparoscopic removal of gastric band after early gastric erosion: case report and review of the literature.

Laparoscopic gastric banding is a popular method for treating morbid obesity. One of the most serious complications is band erosion into the gastric lumen. We present the case of a patient who underwent gastric banding and presented with symptoms of gastrointestinal reflux and mild-to-moderate hypertension, fever, and pain. UGI revealed stomach wall erosion and partial migration of the band into the gastric lumen. The band was laparoscopically removed without any further complications. Migration after laparoscopic gastric banding must be immediately addressed to prevent infection. Close monitoring of the band location during adjustments as well as a high index of suspicion is necessary.

Adult↗

PubMed2005

Topical anesthesia-induced methemoglobinemia in bariatric surgery patients.

Methemoglobinemia leads to rapid oxygen desaturation, requiring prompt recognition and treatment. We present two severely obese patients who developed methemoglobinemia following the use of topical or local anesthetic. This complication was detected by analysis of arterial blood gases, and was successfully treated with methylene blue i.v. and 100% O2 supplementation.

Anastomosis, Roux-en-Y↗

PubMed2005

Development of acute gouty attack in the morbidly obese population after bariatric surgery.

BACKGROUND: Gout is associated with increased body weight. We evaluated the prevalence of gout and acute gouty attacks in the morbidly obese population who underwent bariatric surgery. METHODS: The medical records and operative reports of 1,240 patients who underwent bariatric surgery were reviewed retrospectively for weight parameters, BMI, weight loss, medical history of gout, and onset of acute gouty attacks. RESULTS: Of the 1,240 patients, 5 (0.4%) had been previously diagnosed with gout. 2 of these 5 had acute attacks during the postoperative period, and responded successfully to intravenous colchicine. CONCLUSION: Although rare, gout must be considered a co-morbid illness in obese and morbidly obese patients. Surgeons should be familiar with the signs and symptoms of attacks in the postoperative period, and be knowledgeable in the management.

Acute Disease↗

PubMed2005

Myasthenia gravis improvement after laparoscopic Roux-en-Y gastric bypass.

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m2, and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.

Anastomosis, Roux-en-Y↗

PubMed2004

Routine abdominal drains after laparoscopic Roux-en-Y gastric bypass: a retrospective review of 593 patients.

BACKGROUND: The authors reviewed the benefits of routine placement of closed drains in the peritoneal cavity following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of the study was to determine whether routine closed abdominal drainage provides diagnostic and therapeutic advantages in the presence of complications such as bleeding and leaks. MATERIALS AND METHODS: The medical records of 593 consecutive patients who had undergone LRYGBP from July 2001 through May 2003 were retrospectively reviewed. In all cases, antecolic antegastric LRYGBP was performed. Two 19-Fr Blake closed suction drains were left in place, one at the gastrojejunostomy and the other at the jejunojejunostomy. The incidence of bleeding and leaks was reviewed, and the utility of the drains relative to diagnosis and management was evaluated. RESULTS: Bleeding presented in 24 patients (4.4%); in 8, the diagnosis was based on increased sanguinous output from the drain and decreased hematocrit. None of the patients with intraabdominal bleeding required reoperation. Of the 10 patients (1.68%) who presented with leaks, the diagnosis was made within 48 hours postoperatively in 5 patients (50%), based on the characteristics of the drain output. Nonoperative management with drainage and total parenteral nutrition was accomplished in 5 (50%) of the 10 patients with leaks. There was no mortality in the series. CONCLUSION: The routine use of abdominal drains after LRYGBP appears to be beneficial. Drains allowed early diagnosis of complications and in most cases, the successful treatment of leaks. When bleeding is suspected or documented, appropriate volume replacement therapy is mandatory to maintain adequate hemodynamic parameters. Drain output may orient the surgeon to take preventive measures such as discontinuing anticoagulation and early fluid resuscitation. In this series, in most cases the bleeding spontaneously stopped and no further surgical management was required.

Blood Loss, Surgical↗

PubMedDate not supplied

Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients.

BACKGROUND: The development of an anastomotic stricture at the site of the gastrojejunostomy following Roux-en-Y gastric bypass (RYGBP) is associated with substantial morbidity. Various techniques are available for creating the gastrojejunal anastomosis, including hand-sewing and using a circular or linear stapler, to reduce complication rates. The aim of this study was to assess the incidence of gastrojejunal anastomotic strictures in patients who underwent antecolic antegastric Roux-en-Y gastric bypass (AA-RYGBP) with the use of a linear stapler and to evaluate the outcomes of endoscopic pneumatic dilatation as a treatment option for patients with anastomotic stricture. METHODS: All patients who met the National Institutes of Health (NIH) criteria for bariatric surgery and underwent AA-RYGBP using a linear stapler technique between July 2000 and November 2004 were included in the study. Following Institutional Review Board approval, the medical records of these patients were retrospectively reviewed. Two surgeons performed all of the surgical procedures in this series using a standardized surgical protocol. RESULTS: Between July 2000 and November 2004, 1291 patients (1016 females [79%] and 275 male [11%]) underwent AA-RYGBP. The patients' mean age was 43 years (range, 19-75 years), and mean preoperative body mass index (BMI) was 49.6 kg/m2 (range, 34-97.5 kg/m2). Out of 1291 procedures, 1265 were performed laparoscopically (98.3%), with the reminder performed by laparotomy. A linear stapler was used to create the gastrojejunal anastomosis in all of the procedures. A total of 405 (31%) complications occurred, with gastrojejunal anastomotic strictures the most common complication, found in 94 (7.3%) patients more than 30 days after the procedure. All of these cases of stricture were treated by endoscopic pneumatic dilatation with a through the scope (TTS) balloon, requiring between one and four dilatory sessions. Of the 94 patients (2.1%) who underwent balloon dilatation, 2 developed perforation, only 1 of whom required surgical intervention. The mean postoperative hospital stay for the 94 patients was 4.2 days (range, 2-24 days); there was no perioperative patient mortality. CONCLUSIONS: Our results demonstrate that AA-RYGBP can attain a relatively low complication rate and no mortality. Gastrojejunal anastomotic strictures were the most common complication and were diagnosed 30 days after the procedure. Endoscopic balloon dilatation can be offered as a first-line treatment for gastrojejunal anastomotic strictures. Perforation is a potential complication of this treatment and may necessitate surgical intervention.

Adult↗

PubMedDate not supplied

Laparoscopic Roux-en-Y gastric bypass with linear cutter technique: comparison of four-row versus six-row cartridge in creation of anastomosis.

BACKGROUND: Morbid obesity is refractory to medical treatment. The introduction of laparoscopic linear staplers in the early 1990s contributed to the development of the laparoscopic Roux-en-Y gastric bypass technique. Many series have compared different brands of circular and linear staplers. The purpose of this study was to evaluate the 4-row versus 6-row endoscopic staplers in laparoscopic Roux-en-Y gastric bypass for creation of the anastomosis. METHODS: Between July 2000 and April 2004, 1240 patients underwent laparoscopic Roux-en-Y gastric bypass. The 4-row linear stapler was used in the first 664 cases (group 1) and the 6-row stapler in the latter 576 patients (group 2) to create the anastomosis. The medical records of those patients who developed leaks, gastrogastric fistulas, strictures, or bleeding were reviewed. Strictures were diagnosed using radiologic or endoscopic techniques. RESULTS: Leaks were more frequent in group 2 than in group 1 (1.56% versus 1.05%, respectively, P = .46). Documented bleeding occurred in 15 and 13 patients in groups 1 and 2, respectively (2.26% for both). Strictures were diagnosed in 7.68% of patients in group 1 (51 gastrojejunostomy and 4 jejunojejunostomy), and in 4.3% of those in group 2 (25 gastrojejunostomy stenosis, P = .017). Gastrogastric fistulas were found in 5 patients (.75%) in group 1 and 6 (1.04%) in group 2. CONCLUSION: Using a 6-row instead of a 4-row linear cutter technique to create the anastomosis yielded similar results, but the stricture rate at the gastrojejunal anastomosis was significantly lower with the newer, 6-row staplers.

Adolescent↗