Search PubMed⌕ Search

Biomedical subjects

Robert L Bell

Publications and source records attributed to Robert L Bell.

9 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

Metabolic consequences of bariatric surgery.

Obesity has gained prominence as a main cause of preventable illness and death in the developed world. Surgical therapy for obesity is extremely effective in terms of weight reduction and amelioration of comorbidities. Bariatric procedures are not simply cosmetic operations, however, and involve considerable manipulation of the gastrointestinal tract to induce weight loss. The metabolic consequences of these procedures can be severe if not preempted with relatively simple postoperative precautions on the part of the patient and surgeon. Modern bariatric procedures are much safer than their predecessors, but nutritional and metabolic changes must be anticipated and compensated to fully realize the benefits of surgery. The metabolic consequences of the now outdated jejunoileal bypass, and the more modern Roux-Y gastric bypass, gastroplasty, and biliopancreatic diversion, are presented here, along with specific considerations of patient populations.

Adolescent↗
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

Postoperative considerations for patients with obesity and sleep apnea.

Sleep apnea and obesity are prevalent and often coexisting conditions that challenge medical, anesthetic, and surgical treatment. It is essential to possess knowledge of the magnitude of the sleep disorder as well as concomitant medical comorbidities. Management of obese patients requires a thorough preoperative evaluation and appraisal of anesthetic and operative risks. Postoperatively, these patients can present an additional challenge.

Anesthesia Recovery Period↗
PubMed2003

Surgeon-performed endoscopic dilatation of symptomatic gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: With increasing performance of Roux-en-Y gastric bypass (RYGBP), the postoperative complications are becoming more apparent. Gastrojejunal anastomotic strictures develop in 4.7 to 27% of patients undergoing laparoscopic RYGBP. This paper details two endoscopic techniques for dilating gastrojejunal anastomotic strictures. METHODS: 3 patients developed gastrojejunal anastomotic strictures. In each patient, the operating surgeon performed a diagnostic upper endoscopy, followed by stricture dilatation using either Savary or balloon method. RESULTS: Patients lost a mean weight of 42 kg (range 33-50 kg) before definitive stricture treatment. Once adequately dilated, all patients received an excellent symptomatic result. CONCLUSIONS: For the treatment of gastrojejunal anastomotic strictures, both Savary and balloon dilatation have been efficacious and easy to perform. The endpoint for stricture dilatation is 12 mm or slightly larger. The operating surgeon should acquire a working knowledge of these techniques.

Adult↗
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↗
PubMedDate not supplied

A ten-year, single institution experience with laparoscopic splenectomy.

BACKGROUND AND OBJECTIVES: Laparoscopic splenectomy (LS) is now widely performed and is considered the standard of care for the treatment of certain diseases of the spleen. Although multiple studies have documented the safety and feasibility of laparoscopic splenectomy, little long-term data are available. We present a 10-year, single institution experience with laparoscopic splenectomy to determine trends in procedural outcome data. METHODS: Laparoscopic splenectomy was performed in 109 consecutive, unselected patients with benign or malignant hematological diseases from March 1992 to November 2001. A prospective, longitudinal database, medical record review, and patient interviews were used for data acquisition. During the last 10-years, the annual number of laparoscopic splenectomy was relatively constant. Therefore, patients were divided into 2 cohorts, comparing the first 55 consecutive patients (Group I) with the subsequent 54 patients (Group II) who underwent LS. Data were analyzed using the unpaired Student t test, with values of P < 0.05 considered significant. RESULTS: Mean patient age was 39 years (range, 6 to 79) in Group I and 45 years (range, 13 to 77) in Group II. Total operative time was 151 minutes in Group I and 159 minutes in Group II (NS), estimated blood loss averaged 544 mm in Group I and 308mm in Group II (P = 0.015). The mean specimen weight of the spleen was 288 g in Group I and 512 g in Group II (P = 0.03). Morbidity occurred in 7 of the first 55 patients (13%) and 5 of the next 54 patients (9%). Additionally, 7 conversions to an open operation were necessary in Group I (13%) versus only 1 conversion in Group II (2%). CONCLUSION: A decade of experience with LS shows that it can be performed safely for a wide variety of indications. Over the last 10 years, the average spleen size has increased, yet a significant reduction in blood loss and conversion rate has been achieved.

Adolescent↗