Biomedical subjects

Samuel Szomstein

Publications and source records attributed to Samuel Szomstein.

At least 19 recordsLinked to original sources

PubMed2006

Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity.

BACKGROUND: Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity. STUDY DESIGN: Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed. RESULTS: Sixty-three patients (2.1%) developed anastomotic leaks (open, 2.1%; laparoscopic, 2.1%) at a median of 3 days (range 0 to 28 days) after Roux-en-Y gastric bypass. Symptoms and signs included tachycardia (72%), fever (63%), or abdominal pain (54%). Upper gastrointestinal series and CT demonstrated leaks in only 17 of 56 (30%) and 28 of 50 (56%) patients, respectively; when done jointly, both studies were negative in 30% of patients. The 68 anastomotic leaks occurred at the gastrojejunostomy (49%), excluded stomach (25%), jejunojejunostomy (13%), gastric pouch (9%), and uncertain location (4%). Forty patients (63%) required 58 reoperations for drainage of intraabdominal collections (55%), repair of anastomotic defects (34%), or revision of the leaking anastomosis (11%), with an overall morbidity of 53% and mortality of 10%. Nonoperative treatment was successful in 23 of 26 patients, with an overall morbidity of 61% and no mortality (p=NS versus operative). Operative treatment was more common in patients with hypotension or oliguria (p < 0.01). CONCLUSIONS: Lack of specificity in clinical presentation and imaging studies make diagnosing anastomotic leaks challenging, so operative exploration should be part of the diagnostic algorithm. Nonoperative treatment is safe and effective in a subset of patients who exhibit stable hemodynamic parameters and are known to have controlled leaks.

Adult↗

PubMed2006

Shared medical appointments: new concept for high-volume follow-up for bariatric patients.

BACKGROUND: Shared medical appointments (SMAs) are a new model in patient care. This model was designed to improve patients' access to their physicians and improve physician productivity. The aim of this study was to evaluate patient satisfaction with SMAs after bariatric surgery. METHODS: The medical records of consecutive patients who were followed up after bariatric surgery were retrospectively reviewed. The type of bariatric surgery and type of medical appointment were recorded, as were the patients' replies to the evaluation questionnaires in the SMA group. RESULTS: From April 2004 to December 2004, 277 individual visits were conducted; 242 visits for patients who underwent Roux-en-Y gastric bypass and 35 visits for patients who underwent laparoscopic gastric banding. Thirty-three SMAs occurred during that period--28 SMAs for patients who underwent Roux-en-Y gastric bypass and 5 SMAs for patients who underwent laparoscopic gastric banding. Of the patients who initially participated in an SMA, 91% scheduled a subsequent SMA, and 96% indicated that they would recommend SMAs to others. On a scale of 1 to 5 (1, poor and 5, excellent), patients graded their overall experience with SMAs as 4.5. Other parameters in the questionnaire all ranked between 4 and 5. The average waiting period for an appointment before the implementation of SMAs was 57.7 days (range 50-65) for new patients and 50 days (range 20-72) for former patients. After the implementation of SMAs, the average waiting period was 25 days (range 8-42) for new patients (P = 0.0046) and 20.3 days (range 0-42) for former patients (P = 0.06). CONCLUSION: The SMA offers the patient prompt access to medical care, enables high-volume follow-up, with high satisfaction rates.

Aftercare↗

PubMed2006

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases.

BACKGROUND: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. METHODS: Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. RESULTS: Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. CONCLUSIONS: AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.

Aged↗

PubMed2006

Laparoscopic lysis of adhesions.

BACKGROUND: Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. METHODS: The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique. RESULTS: The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%-93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%-2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4-6 days in most series. CONCLUSIONS: Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.

Abdomen↗

PubMed2006

Challenges of laparoscopic colectomy in the obese patient: a review.

BACKGROUND: Perioperative care of clinically severely obese patients presents numerous unique challenges. These patients have distinctive issues with regard to cardiovascular, pulmonary, and thromboembolic complications. In addition, hospital equipment must be able to accommodate the body habitus of this population. METHODS: A Medline search using the terms "morbid obesity," "colon resection," "obesity comorbidities," "laparoscopic colectomy," "perioperative challenges," and "risk factors" was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each publication. RESULTS: The authors discussed the most relevant challenges surgeons encounter in the perioperative setting when treating obese patients. COMMENTS: The management of the morbidly obese patient requires meticulous preoperative, intraoperative, and postoperative care. Colorectal surgeons should be familiar with obesity-related problems when treating colorectal disease processes in this patient population. The associated comorbid illnesses in this population, as well as the technical difficulties regularly posed by them, make laparoscopic colectomy a more challenging procedure than normally encountered in the nonobese patient population.

Colectomy↗

PubMed2006

Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: The resultant derangement of the normal gastrointestinal anatomy after a gastric bypass procedure increases the incidence of, and level of difficulty diagnosing, partial small bowel obstruction (SBO) in morbidly obese patients. We evaluated the diagnostic methods for partial SBO and the clinical characteristics according to the time after initial operation. STUDY DESIGN: Data of 1,400 consecutive patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass between 2001 and 2004 were retrospectively analyzed. RESULTS: Partial SBO developed in 21 (1.5%) patients after laparoscopic Roux-en-Y gastric bypass. Five of 15 patients were preoperatively diagnosed with SBO by a gastrograffin study and CT scan diagnosed 17 of 19 patients (p = 0.002). Causes of SBO included jejunojejunostomy stenosis (n = 6), adhesions (n = 5), incarcerated ventral hernia (n = 5), internal hernia (n = 3), and other (n = 2). The majority of patients (n = 19) underwent surgical treatment. CONCLUSIONS: The most frequent cause of early SBO is jejunojejunal anastomotic stenosis. CT scan is a more accurate diagnostic tool for detecting partial SBO, compared with use of a gastrograffin study. Operation remains the most appropriate and definitive treatment for this complication and the laparoscopic approach is a feasible and safe surgical treatment option.

Adult↗

PubMed2006

Achalasia after vertical banded gastroplasty for morbid obesity: A case report.

Achalasia is an unusual motility disorder that can be seen in conjunction with obesity. The prevalence of achalasia is unknown in obese patients and when present, the clinical characteristics are atypical. We report a case of achalasia that was diagnosed 13 years after a vertical-banded gastroplasty was performed.

Aged↗

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↗

PubMed2006

Gastric bezoar after laparoscopic Roux-en-Y gastric bypass.

Gastric bezoar is an uncommon complication following Roux-en-Y gastric bypass (RYGBP). We report two cases of bezoar formation that occurred following laparoscopic RYGBPs. In both cases, the patients presented with abdominal pain, nausea, and "frothy" vomiting. The patients were successfully treated by endoscopic fragmentation and removal of the bezoar.

Abdominal Pain↗

PubMed2006

Management of ulcerative colitis in the morbidly obese patient: is bariatric surgery indicated?

Ulcerative colitis and obesity share a systemic chronic inflammatory response manifested by increased inflammatory markers. There are data suggesting a benefit in both diseases after inflammatory markers are decreased. We present a 39-year-old morbidly obese male with a history of ulcerative colitis who manifested significant symptomatic improvement after an 86.8% excess weight loss following gastric bypass surgery. We believe that this result may have been due to a reduction of inflammatory markers secondary to considerable weight loss. Although to our knowledge there are no publications showing a direct relationship between symptomatic improvement of ulcerative colitis and weight loss in the obese patient, we believe that weight loss surgery could become a promising tool in the treatment of ulcerative colitis when associated with morbid obesity.

Adult↗

PubMed2006

Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed surgical procedures for weight reduction in the United States. Currently, laparoscopic sleeve gastrectomy (LSG) is being explored. The aim of this study was to assess the safety and short-term efficacy of LSG as a treatment option for weight reduction. METHODS: Data of all patients who underwent LSG for treatment of morbid obesity between November 2004 and March 2006 and completed the 3- and 6-month follow-up visits at the time of the study, were retrospectively reviewed. Data collected included demographics, operative time, length of stay, postoperative complications, and degree of weight reduction. RESULTS: Of the 62 patients who underwent LSG performed by two surgeons, the data of 30 patients (7 males and 23 females) were further analyzed. Mean preoperative BMI was 41.4 (33-59) kg/m(2). Mean operative time was 80 min (range 65-130). Mean hospital stay was 3.2 days (range 2 to 25). Mean weight loss at 3 and 6 months following the procedure was 22.7 kg and 30.5 kg respectively, and mean % excess weight loss (EWL) was 40.7 and 52.8, respectively. Three patients were considered to have mild complications, and one patient had a major complication that necessitated surgical intervention. There was no mortality. CONCLUSIONS: In the short-term, LSG is a safe and effective treatment option.

Adolescent↗

PubMed2005

Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery.

BACKGROUND: Nutritional deficiencies are a recognized complication of bariatric surgery. Thiamine deficiency has been reported as a possible consequence of both restrictive and malabsorptive bariatric procedures. Most of the reported cases occurred after Roux-en-Y gastric bypass (RYGB) surgery; fewer were described after biliopancreatic diversion, vertical banded gastroplasty, or duodenal switch. Adults who have a high carbohydrate intake derived mainly from refined sugars and milled rice are at greater risk of developing thiamine deficiency, because thiamine is absent from fats, oils, and refined sugars. Currently, no reports have evaluated the preoperative thiamine status of bariatric patients. The aim of this study was to evaluate the degree of thiamine deficiency in obese patients before bariatric surgery at our institution. METHODS: The medical records of consecutive patients who underwent laparoscopic RYGB or laparoscopic adjustable gastric banding at our institution between March 2003 and February 2004 were retrospectively reviewed. Patients were selected for this study on the basis of predetermined criteria. Preoperative thiamine levels were retrospectively recorded. Excluded from this study were patients who had been taking multivitamins or other nutritional supplements before surgical intervention, had a history of frequent alcohol consumption, any malabsorptive diseases, or previous restrictive-malabsorptive surgical interventions, such as RYGB, biliopancreatic diversion, or adjustable gastric banding, according to the initial evaluation and questionnaire. RESULTS: Of 437 consecutive patients who underwent laparoscopic RYGB or laparoscopic adjustable gastric banding, 303 were included in the study. Forty-seven patients (15.5%) presented with low preoperative thiamine levels. The mean age and body mass index of these patients was 46 years and 60 kg/m(2), respectively. Male patients presented with greater mean preoperative thiamine levels (3.2 microg /dL) than female patients (2.4 microg/dL). CONCLUSION: Obese patients undergoing bariatric surgery may have significant thiamine deficiency before surgery.

Adolescent↗

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 gastric bypass for refractory morbid obesity.

Morbid obesity has reached epidemic proportions in the United States. Laparoscopic gastric bypass is rapidly becoming the procedure of choice for treatment of morbid obesity. Results demonstrate that the surgery is technically safe. Outcomes are similar to open gastric bypass,but with markedly lower incidences of wound-related and cardiopulmonary complications. Patients also have shorter hospital stay, decreased pain and faster recovery.

Anastomosis, Roux-en-Y↗

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

Renal failure, glomerulonephritis and morbid obesity: improvement after rapid weight loss following laparoscopic gastric bypass.

There is experimental evidence but very few human studies that suggest a role for obesity in the formation and progression of some glomerular lesions. We report the case of a morbidly obese male with hematuria and proteinuria that was subsequently diagnosed with renal failure which required dialysis. Histological findings of the renal biopsy performed during a laparoscopic gastric bypass are presented. His renal failure resolved with the weight loss.

Acute Kidney Injury↗