Biomedical subjects

Ninh T Nguyen

Publications and source records attributed to Ninh T Nguyen.

At least 37 records · Page 2Linked to original sources

PubMed2005

Staged laparoscopic Roux-en-Y: a novel two-stage bariatric operation as an alternative in the super-obese with massively enlarged liver.

In a subset of super-obese patients, the one-stage laparoscopic Roux-en-Y gastric bypass (RYGBP) can be associated with significant morbidity and mortality. In a previous effort to reduce the perioperative risks associated with the super-obese, a two-stage operation was devised. This two-stage operation consisted of a sleeve gastrectomy (1st stage) followed by a RYGBP or duodenal switch procedure (2nd stage). We find that the primary limiting factor making laparoscopic gastric bypass challenging in the super-obese is the volume of the left lobe of the liver. A greatly thickened left lobe of the liver obscures visualization of the gastroesophageal junction and angle of His so that a sleeve gastrectomy is difficult to construct. In this report, we describe a novel method utilizing a staged Roux-en-Y procedure. Instead of performing a restrictive operation (sleeve gastrectomy) as the initial procedure, we fashion a modified Roux-en-Y with a low gastrojejunal anastomosis and a larger gastric pouch encompassing the gastric fundus. The low anastomosis obviates the need for exposure of the gastro-esophageal junction and angle of His. At the 2nd stage procedure, completion sleeve gastrectomy of the gastric fundus is performed at an interval of 6-12 months after the 1st stage operation.

Anastomosis, Roux-en-Y↗

PubMed2005

Monitor height affects surgeons' stress level and performance on minimally invasive surgery tasks.

This study investigated the effect of monitor height on surgeons' workload and performance during simulated minimally invasive surgery (MIS). Fourteen volunteer subjects (7 experienced, 7 inexperienced) performed a cutting task in a training box at a standard MIS station with the video monitor positioned in random order at, below (-35 degrees), and above (+15 degrees) the subject's eye level. Task time and error, difficulty and discomfort, head orientation, trapezius and neck muscle activity, and skin conductance were recorded. The experienced subjects performed the task faster, with less error, and with less difficulty than did the inexperienced subjects. For the experienced subjects, error decreased when the monitor was lowered. Difficulty and discomfort increased at the high monitor position. As the monitor was lowered, the head pitched forward, and paraspinal cervical muscle activity increased. Variability in sternocleidomastoid activity increased both at the low and high monitor positions. The results show that monitor height affects both performance and workload. The monitor should be lowered to reduce error and task difficulty but not so low as to produce excessive neck flexion.

Adult↗

PubMed2005

Bioabsorbable staple line reinforcement for laparoscopic gastrointestinal surgery.

Laparoscopic gastrointestinal (GI) surgery often requires transection and reconstruction of the GI tract and division of vascular pedicles. Intraoperative staple line bleeding and postoperative GI hemorrhage are reported complications. Prevention of staple line bleeding includes oversewing of the staple line or more recently the use of staple line reinforcement sleeves as an adjunct on the stapler. The results of bioabsorbable glycolide copolymer sleeves (Seamguard, W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) as staple line reinforcement during 44 laparoscopic GI operations were reviewed. The charts were analyzed retrospectively for demographics, quantity of staple line reinforcement material used, operative time, blood loss, intraoperative complications, postoperative bleeding or leak, and serial hemoglobin. The study group of 44 patients included 17 males and 27 females, with a median age of 44 years. The laparoscopic GI operations performed were laparoscopic cystgastrostomy (n=1), esophagus cancer staging (n=2), esophagectomy (n=2), colectomy (n=3), gastrectomy (n=5), appendectomy (n=9), and Roux-en-Y gastric bypass (n=22). The median number of staple line reinforcement sleeves used per operation was one for appendectomy and laparoscopic cancer staging, five for gastrectomy and esophagectomy, and seven for gastric bypass and colectomy. The mean blood loss was 86 +/- 22 mL. No intraoperative staple line disruptions occurred. Intraoperative staple line bleeding was minimal and few staple lines required oversewing. One patient developed GI hemorrhage on postoperative day five after being involved in a motor vehicle accident. The mean hemoglobin decreased from 13.9 +/- 1.6 g/dL at baseline to 12.6 +/-1.4 g/dL on the first postoperative day. No postoperative leaks or abscesses occurred. This study demonstrates that bioabsorbable glycolide copolymer staple line sleeves is safe and effective in prevention of intraoperative staple line bleeding and postoperative GI hemorrhage in 44 intra-abdominal GI operations.

Absorbable Implants↗

PubMed2004

Trends in utilization and outcomes of laparoscopic versus open appendectomy.

BACKGROUND: Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. METHODS: Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. RESULTS: Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260). CONCLUSIONS: Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.

Adolescent↗

PubMed2004

The practice of bariatric surgery at academic medical centers.

The growing demand for laparoscopic bariatric surgery has led to an increase in the development of new bariatric surgical practices. Proper hospital facilities and an experienced bariatric surgical team are necessary to ensure optimal patient results. We surveyed academic centers participating in the University HealthSystem Consortium to examine the current practice of bariatric surgery. The survey questioned (1) availability of resources and equipment designed for the morbidly obese, (2) accidents, equipment problems, and workers' compensation relating to the care of bariatric surgical patients, (3) credentialing of bariatric surgeons, and (4) suggestions for improvements in the bariatric surgery program. Twenty-five institutions that perform bariatric surgery responded. Although the majority of institutions noted that they had basic bariatric equipment, some organizations did not have facility resources such as high-weight operating room tables and computed tomography scanners or transfer devices. Twenty-eight percent of institutions reported having accidents or equipment problems and 40% of institutions had workers' compensation claims relating to the care of bariatric patients. With regard to credentialing, 60% of institutions required the surgeons to have performed a minimum number of procedures prior to granting privileges. Suggested improvements included the need for more specialized bariatric equipment, enhancement of the education of all members of the bariatric surgical team, and designation of a bariatric physician who would coordinate care. This survey of bariatric surgery practices at academic medical centers demonstrates that the practice of bariatric surgery could be improved with regard to availability of bariatric equipment and resources and credentialing of surgeons.

Academic Medical Centers↗

PubMed2004

The efficacy of fibrin sealant in prevention of anastomotic leak after laparoscopic gastric bypass.

BACKGROUND: Anastomotic leak after laparoscopic gastric bypass (GBP) can result in significant morbidity, mortality, and consumption of healthcare resources. Fibrin sealant has been used clinically in the prevention of leak; however, its efficacy has not been clearly demonstrated. The aims of this study were to (1) develop an iatrogenic leak model in swine, (2) examine the efficacy of fibrin sealant in sealing iatrogenic anastomotic leak, and (3) review our experience with the use of fibrin sealant in 66 patients who underwent laparoscopic GBP. METHODS: This study was performed in three phases. In phase 1, laparoscopic gastrojejunostomy was performed in adult swine with iatrogenic disruption of the anastomotic staple line. The size of disruption was sequentially increased (6- to 12-F opening) until a leak model was developed. In phase 2, 16 animals underwent laparoscopic gastrojejunostomy with a 12-F disruption of the anastomosis; 10 animals (study group) had fibrin sealant (Tisseel VH) applied on the disrupted anastomosis and 6 animals (control group) did not receive fibrin sealant. Animals were sacrificed on postoperative day 5 or earlier if peritonitis developed and were examined for sealing of the anastomotic disruption and the presence of intraabdominal abscess. In phase 3, the outcome of 66 consecutive patients who underwent laparoscopic GBP with fibrin sealant applied at the gastrojejunostomy was reviewed. RESULTS: In phase 1, an anastomotic leak model was developed with a 12-F disruption of the staple line. In phase 2, two control animals required early sacrifice for bile peritonitis; three control animals had intraabdominal abscess discovered at sacrifice and one animal did not have any evidence of intraabdominal abscess or leak. Of the 10 animals in the study group, all survived until sacrifice and none of these animals had evidence of intraabdominal abscess or persistent leak. Therefore, 83% of animals in the control group developed either leak or abscess compared to 0% in the study group (P < 0.01, Fisher's exact test). Clinically, no leak or intraabdominal abscess developed in 66 patients who underwent laparoscopic GBP with the use of fibrin sealant. CONCLUSIONS: An anastomotic leak model was developed in swine with disruption of the stapled gastrojejunostomy to a 12-F opening. The use of fibrin sealant significantly reduces leak and abscess complication. Our results support the tissue sealing property of fibrin sealant and its use on high-risk gastrointestinal anastomosis.

Abscess↗

PubMed2004

The relationship between hospital volume and outcome in bariatric surgery at academic medical centers.

OBJECTIVE: To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. SUMMARY BACKGROUND DATA: The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as "Centers of Excellence." Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume-outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. METHODS: Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50-100 cases/year), and low-volume hospitals (<50 cases/year). RESULTS: There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). CONCLUSIONS: Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume-outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.

Academic Medical Centers↗

PubMed2004

Bowel obstruction after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication. METHODS: We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management. RESULTS: 9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 +/- 12 years, with mean BMI 47 +/- 9 kg/m(2). 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 +/-16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 +/- 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). CONCLUSIONS: Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.

Adult↗

PubMed2004

Laparoscopic Roux-en-Y gastric bypass vs. laparoscopic adjustable gastric banding for treatment of morbid obesity.

Bariatric surgery is a rapidly growing discipline in General Surgery. Roux-en-Y gastric bypass (GBP) is currently the most commonly performed bariatric surgical procedure for treatment of morbid obesity in the United States (U.S). The laparoscopic approach to (GBP) has led to a greater acceptance for surgical treatment of morbid obesity by the public and, in return, more surgeons are becoming interested in learning laparoscopic bariatric surgery to meet the high demand. Laparoscopic adjustable silicone gastric banding was approved in the U.S. by the Food and Drug Administration (FDA) for clinical use in 2001, and is emerging as an alternative laparoscopic option in management of morbid obesity. This chapter reviews the indications, techniques, and outcomes of laparoscopic GBP vs. laparoscopic adjustable gastric banding. The advantages and disadvantages of laparoscopic adjustable gastric banding compared to laparoscopic GBP is discussed.

Anastomosis, Roux-en-Y↗

PubMed2004

Application of robotics in general surgery: initial experience.

Robotic surgery was recently approved for clinical use in general abdominal surgery. The aim of this study was to review our experience with the da Vinci surgical system during laparoscopic general surgical procedures. Eighteen patients underwent robotically assisted laparoscopic abdominal surgery between June 2002 and March 2003. Main outcome measures were operative time, room setup time, robotic arm-positioning and surgical time, blood loss, conversion to laparoscopy, length of stay, and morbidity. The types of robotically assisted laparoscopic procedures were excision of gastric leiomyoma (n = 1), Heller myotomy (n = 1), cholecystectomy (n = 2), gastric banding (n = 2), Nissen fundoplication (n = 4), and gastric bypass (n = 8). The mean room setup time was 63 +/- 14 minutes, and the mean robotic arm-positioning time was 16 +/- 7 minutes. Conversion to laparoscopy occurred in two (11%) of 18 cases because of equipment difficulty (n = 1) and technical difficulty (n = 1). Estimated blood loss was 91 +/- 71 mL. The mean operative time was 156 +/- 42 minutes, and the robotic operative time was 27% of the total operative time. The mean length of hospital stay was 2.2 +/- 1.5 days. There was one postoperative wound infection and one anastomotic stricture. Robotically assisted laparoscopic abdominal surgery is feasible and safe; however, the theoretical advantages of the da Vinci surgical system were not clinically apparent.

Adult↗

PubMed2003

Complications after laparoscopic gastric bypass: a review of 3464 cases.

HYPOTHESIS: The type and frequency of complications after open Roux-en-Y gastric bypass (GBP) have changed with the development of laparoscopic technique. BACKGROUND: The number of laparoscopic GBP cases performed in the United States has increased dramatically during the past several years. We compared the type and frequency of complications after laparoscopic and open GBP. METHODS: We searched MEDLINE from January 1, 1994, through December 31, 2002, using the keywords morbid obesity, laparoscopy, bariatric surgery, and gastric bypass. We selected studies on laparoscopic or open GBP with more than 50 patients and published in the English language for analysis. We excluded studies with reoperative Roux-en-Y GBP cases or other bariatric procedures. The type and frequency of postoperative complications were recorded from each study. We used chi2 and Fisher exact tests to determine statistical significance. RESULTS: Ten laparoscopic GBP studies with 3464 patients and 8 open GBP studies with 2771 patients were considered. The mean of the reported average age for patients undergoing laparoscopic GBP was 41 years compared with 43 years for open GBP. The mean percentages of female patients were 87% for laparoscopic GBP and 82% for open GBP; the mean reported average body mass index (calculated as weight in kilograms divided by the square of height in meters), 48.7 and 49.5, respectively. Compared with open GBP, laparoscopic GBP was associated with a decrease in the frequency of iatrogenic splenectomy, wound infection, incisional hernia, and mortality; however, there was an increase in the frequency of early and late bowel obstruction, gastrointestinal tract hemorrhage, and stomal stenosis. There were no significant differences in the frequency of anastomotic leak, pulmonary embolism, or pneumonia. CONCLUSIONS: The type and frequency of postoperative complications after laparoscopic and open GBP are different. Certain complications increase with laparoscopic GBP, probably owing to the learning curve of this complex procedure, whereas other complications decrease because of the advantages of the smaller access incision.

Adult↗

PubMed2003

Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass.

Anastomotic stricture is a frequent complication after Roux-en-Y gastric bypass (GBP). We evaluated the frequency of anastomotic stricture following laparoscopic GBP using a 21 mm. vs. a 25 mm circular stapler for construction of the gastrojejunostomy and the safety and efficacy of endoscopic balloon dilation in the management of anastomotic stricture. We reviewed data on 29 patients in whom anastomotic strictures developed after laparoscopic GBP. All strictures were managed with endoscopic balloon dilation using an 18 mm balloon catheter under fluoroscopic guidance. Main outcome measures were the number of anastomotic strictures in patients in whom the 21 mm (vs. 25 mm) circular stapler was used to create the gastrojejunostomy, time interval between the primary operation and symptoms, complications of endoscopic balloon dilation, the number of patients with resolution of obstructive symptoms, and body weight loss. There were 28 females with a mean age of 39 years and a mean body mass index of 48 kg/m(2). Anastomotic stricture occurred significantly more frequently with the use of the 21 mm compared to the 25 mm circular stapler (26.8% vs. 8.8%, respectively; P<0.01). The median time interval between the primary operation and presentation of stricture was 46 days. After the initial dilation, recurrent stricture developed in 5 (17.2%) of 29 patients. These five patients underwent a second endoscopic dilation, and only one of these five patients required a third endoscopic dilation. None of the 29 patients required more than three endoscopic dilations. The mean percentage of excess body weight loss at 1 year for patients in whom the 21 mm circular stapler was used for creation of the gastrojejunostomy was similar to that for patients in whom the 25 mm circular stapler was used (68.2% vs. 70.2%, P=0.8). In this series the rate of anastomotic stricture significantly decreased with the use of the 25 mm circular stapler for construction of the gastrojejunostomy without compromising weight loss. Endoscopic balloon dilation is a safe and effective option in the management of anastomotic stricture following laparoscopic GBP.

Adult↗

PubMed2003

Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures.

BACKGROUND: Transhiatal and transthoracic esophagectomy are common approaches for esophageal resection. The literature is limited regarding the combined thoracoscopic and laparoscopic approach to esophagectomy. The aim of this study was to evaluate the outcomes of combined thoracoscopic and laparoscopic esophagectomy for the treatment of benign and malignant esophageal disease. STUDY DESIGN: We performed a retrospective chart review of 46 consecutive minimally invasive esophagectomies performed between August 1998 and September 2002. Indications for esophagectomy were carcinoma (n = 38), Barrett's esophagus with high-grade dysplasia (n = 3), and recalcitrant stricture (n = 5). Of 38 patients with carcinoma 23 (61%) had neoadjuvant therapy. The main outcome measures were operative time, blood loss, length of intensive care unit and hospital stay, conversion rate, morbidity, mortality, pathology, disease recurrence, and survival. RESULTS: Approaches to esophagectomy were thoracoscopic and laparoscopic esophagectomy (n = 41), thoracoscopic and laparoscopic Ivor Lewis resection (n = 3), abdominal only laparoscopic esophagogastrectomy (n = 1), and hand-assisted laparoscopic transhiatal esophagectomy (n = 1). Minimally invasive esophagectomy was successfully completed in 45 (97.8%) of 46 patients. The mean operative time was 350 +/- 75 minutes and the mean blood loss was 279 +/- 184 mL. The median length of intensive care unit stay was 2 days and median length of stay was 8 days. Major complications occurred in 17.4% of patients and minor complications occurred in 10.8%. Late complications were seen in 26.1% of patients. The overall mortality was 4.3%. Among the 38 patients who underwent esophagectomy for cancer the 3-year survival was 57%. In a mean followup of 26 months there was no trocar site or neck wound recurrences. CONCLUSIONS: A thoracoscopic and laparoscopic approach to esophagectomy is technically feasible and safe for the treatment of benign and malignant esophageal disease. With a mean followup of 26 months thoracoscopic and laparoscopic esophagectomy appears to be an oncologically acceptable surgical approach for the treatment of esophageal cancer.

Combined Modality Therapy↗

PubMed2003

Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass.

BACKGROUND: Pneumoperitoneum has been shown to reduce hepatic portal blood flow and alter postoperative hepatic transaminases. This study evaluated the changes in hepatic function after laparoscopic and open gastric bypass (GBP). METHODS: Thirty-six morbidly obese patients were randomly assigned to undergo either laparoscopic (n = 18) or open (n = 18) GBP. Liver function tests--total bilirubin (T Bil), gamma GT (GGT), albumin, alkaline phosphatase (ALP), aspartate transferase (AST), alanine transferase (ALT)--and creatine kinase levels were obtained preoperatively and at 1, 24, 48, and 72 hours postoperatively. RESULTS: The two groups were similar in age, sex, and body mass index. Albumin and ALP levels decreased while T Bil and GGT levels remained unchanged from baseline in both groups without significant difference between the two groups. After laparoscopic GBP, ALT and AST transiently increased by sixfold and returned to near baseline levels at 72 hours. After open GBP, ALT and AST transiently increased by fivefold to eightfold and returned to near baseline levels by 72 hours. Creatine kinase level was significantly lower after laparoscopic GBP than after open GBP at 48 and 72 hours postoperatively. There was no postoperative liver failure or mortality in either group. CONCLUSIONS: Laparoscopic GBP resulted in transient postoperative elevation of hepatic transaminase (ALT, AST) but did not adversely alter hepatic function to any greater extent than open GBP. Creatine kinase levels were lower after laparoscopic GBP reflecting its lesser degree of abdominal wall trauma.

Adult↗

PubMed2003

Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients.

BACKGROUND: Photodynamic therapy (PDT) utilizes a photosensitizing agent, light, and oxygen to endoscopically ablate cancer cells. This review summarizes our experience with PDT for the palliation of bleeding or obstructing esophageal cancer (EC). METHODS: All patients with bleeding or obstructing EC treated with PDT from November 1996 through June 2002, were reviewed. After Photofrin II injection, nonthermal light treatment was delivered endoscopically. Dysphagia scores, duration of palliation, reinterventions, complications, and survival after treatment were reviewed. RESULTS: A total of 215 patients underwent 318 courses of PDT for bleeding (n = 15), obstruction (n = 277), bleeding and obstruction (n = 18), or other indications (n = 8). Tumor histology included 179 adenocarcinomas, 33 squamous cell carcinomas, and 3 undifferentiated. Seventy-five percent of EC were in the distal esophagus. In 85% of courses for obstruction, mean dysphagia scores improved pre- and post-PDT. The mean dysphagia-free interval was 66 days. Supplemental nutrition was discontinued after PDT in 8 of 27 patients (30%). Thirty-five patients required stent placement after PDT with a mean interval to reintervention of 58.5 days. PDT complications included perforation (2% of treatment courses), stricture (2%), Candida esophagitis (2%), pleural effusions (4%), and sunburn (6%). The procedure-related mortality rate was 1.8%, and median survival was 4.8 months. CONCLUSIONS: PDT offers effective palliation for patients with obstructing EC in 85% of treatment courses. The ideal EC patient for PDT palliation has an obstructing endoluminal cancer. Patients living more than 2 months may require reintervention to maintain palliation of malignant dysphagia, and a multimodality treatment approach is common.

Adult↗

PubMed2003

Factors associated with operative outcomes in laparoscopic gastric bypass.

BACKGROUND: Laparoscopic gastric bypass (GBP) is becoming a common approach for treatment of morbid obesity. We analyzed preoperative factors that may be associated with operative outcomes in laparoscopic GBP. STUDY DESIGN: This prospective study evaluates 150 consecutive laparoscopic GBP procedures performed by a single surgeon. Preoperative factors were grouped into three categories: 1) patient-specific (gender, age, abdominal surgical history, smoking), 2) obesity-specific (body mass index, hypertension, diabetes, sleep apnea), and 3) procedure-specific (operative experience of the surgeon [75 cases or less versus more than 75 cases]). Length of operation (240 minutes or less versus more than 240 minutes), postoperative complications (yes versus no), major complications (yes versus no), reoperation (yes versus no), and length of hospital stay (4 days or less versus more than 4 days) were the operative outcomes considered. In this series all patients who had a major complication required a reoperation. Data were analyzed using univariate and multiple logistic regression analyses. RESULTS: Operative experience of surgeon (75 cases or less) was associated with lengthy operative time (adjusted odds ratio [AOR], 3.8; 95% confidence interval [CI], 1.7 to 8.3), major complications (AOR, 15.0; 95% CI, 1.5 to 143.0), and a lengthy (more than 4 days) hospital stay (AOR, 4.5; 95% CI, 1.1 to 18.0). Higher patient age (50 years or more) was associated with more postoperative complications (AOR, 11.4; 95% CI, 3.0 to 43.1) and major complications (AOR, 7.6; 95% CI, 1.1 to 48.7). Male gender also was associated with more postoperative complications (AOR 5.2; 95% CI, 1.1 to 23.1). Obesity-related comorbidities, body mass index, past abdominal surgical history, and smoking had no statistical association with operative outcomes in this study. CONCLUSIONS: There is an association of clinical outcomes after laparoscopic GBP with the age and gender of the patient and the operative experience of the surgeon. An operative experience of more than 75 laparoscopic GBP cases was associated with decreases in operative time, length of hospital stay, and number of major complications.

Adult↗

PubMed2003

Early gastrointestinal hemorrhage after laparoscopic gastric bypass.

BACKGROUND: Early gastrointestinal (GI) hemorrhage after open gastric bypass has been infrequently reported. The aim of this study was to examine the incidence of early GI hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP), its presentation, and possible treatment options. METHODS: A retrospective review of 5 patients who developed early postoperative GI hemorrhage after LRYGBP was performed. The charts were reviewed for demographics, clinical presentation, diagnostic evaluation, and treatment. All patients underwent a transected LRYGBP with creation of the gastrojejunostomy anastomosis with a circular stapler and the jejunojejunostomy anastomosis with a linear stapler. RESULTS: Of the 155 patients in our database who underwent LRYGBP, 5 (3.2%) developed early clinical GI hemorrhage. There were 2 males with an average age of 40 years. Clinical presentations of GI hemorrhage were hematemesis (2 patients), bright red blood per rectum (1 patient), melena (1 patient), and hypotension (1 patient). A diagnostic study (nuclear scintigraphy) was performed in only 1 of 5 patients. 3 of 5 patients were managed nonoperatively; 2 patients required fluid and blood resuscitation, and the other patient was managed without blood transfusion. The onset of hemorrhage in these 3 patients occurred 24 hours postoperatively or later. 2 of 5 patients required operative intervention for control of hemorrhage. The onset of hemorrhage or hypotension in these 2 patients occurred within 12 hours after surgery. The sites of hemorrhage were at the gastric remnant staple-lines in 1 patient and at the gastrojejunostomy and gastric remnant staple-lines in the other patient. CONCLUSION: Early GI hemorrhage is a potential complication after transected LRYGBP. Early reoperative intervention should be performed for patients with hemodynamic instability and patients with early onset of hemorrhage after surgery.

Adult↗

PubMed2003

Laparoscopic resection of gastric stromal tumor: a tailored approach.

Many different laparoscopic approaches to resection of gastric stromal tumor have been described in the literature. We reviewed our experience of laparoscopic approaches to surgical resection of gastric stromal tumors seven in six consecutive patients. The tumor locations were the gastric cardia (n = 2), gastroesophageal junction (n = 1), gastric fundus (n = 2), and gastric antrum (n = 2). Laparoscopic localization of endoluminal tumors included intraoperative endoscopy, laparoscopic ultrasound, and laparoscopic palpation. There were five males with a mean age of 57 years. Laparoscopic approaches to resection were laparoscopic wedge resection (n = 4) for tumors in the gastric fundus and antrum, laparoscopic enucleation (n = 2) for tumors in the gastric cardia, and transgastric endoluminal resection (n = 1) for a tumor located at the gastroesophageal junction. There was no conversion to laparotomy. The mean operative time was 143 +/- 54 minutes and mean blood loss was 57 +/- 27 mL. None of the patients required intensive care stay. The mean length of hospital stay was 3 days. There were no major or minor complications and no mortality. Surgical pathology demonstrated gastric stromal tumor with less than 2/50 mitosis per high power field in all seven specimens. Tumor size ranged from 2.8 cm to 7.1 cm in greatest diameter. There has been no tumor recurrence with a mean follow-up of 9 months. Laparoscopic resection of benign gastric stromal tumor is safe and feasible. The laparoscopic approaches to surgical resection should be tailored based on the location and characteristics of the tumor.

Adult↗