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Obesity is becoming more common in the United States, affecting > or = 30% of adults aged 20 years and older. Obesity (body mass index 30) is ranked second only to tobacco use as a preventable cause of death in the United States. Roux-en-Y gastric bypass (RYGBP) is being performed at a rapidly increasing rate, and laparoscopic Roux-en-Y gastric bypass (LRYGBP) surgery is frequently chosen rather than an open approach because of lower morbidity rates. One of the complications of LRYGBP includes small bowel obstruction (SBO) secondary to internal herniation. When RYGBP is performed through the open approach, SBO is most commonly caused by adhesions. The challenge with these patients is that the presenting signs, symptoms, and physical and radiological examinations may be vague, nonspecific, and/or nondiagnostic. Internal hernias that result as a complication of LRYGBP occur in 1 of 3 places. These locations include the transverse mesocolon, the jejunal mesenteric defect at the level of the jejunojejunostomy, and Petersen's space, which is the area between the mesentery of the Roux limb and the transverse mesocolon. We report the case of a 45-year-old woman who presented with SBO secondary to Petersen's hernia. The clinical presentation and radiologic studies are discussed.
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PMID:Internal hernia after laparoscopic gastric bypass surgery: a case report and literature review. 1865 63

Obesity has been proven to be a significant independent risk factor for hiatal hernia. In morbidly obese patients, the usual techniques to improve gastroesophageal reflux after hiatal hernia repair could have poorer outcomes than in the general population. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be an effective procedure in controlling symptoms and complications of gastroesophageal reflux in these patients. Therefore, LRYGBP is one of the most frequent procedures performed in bariatric surgery. The authors report a case of a 41-year-old man with a body mass index (BMI) of 44.6 kg/m(2) who was diagnosed with giant type III hiatal hernia. A laparoscopic approach for both hiatal hernia repair and LRYGBP was performed. At 6 months follow-up, the patient has lost 30% of excess body weight (BMI 34.4), and there is no evidence of recurrence of the esophageal hernia.
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PMID:Treatment of morbid obesity and hiatal paraesophageal hernia by laparoscopic Roux-en-Y gastric bypass. 1877 50

Today, plastic surgeons are increasingly faced with the problem of complex abdominal wall reconstruction. Obesity, bariatric surgery, and failed prior herniorrhaphy contribute to high rates of hernia recurrence in these difficult tertiary cases. We reviewed 50 consecutive complex abdominal wall reconstructions to identify the roles of 3 technical variables in successful outcomes: use of mesh, use of a flap buttress to reinforce the fascial repair, and the use of concomitant body-contouring techniques. Six groups were identified based on the presence or absence of each of these variables. Incidence of hernia recurrence and incidence of complications were compared for each group. Patient satisfaction with reconstructive outcome was assessed at follow-up using a 5-point scale. At a mean follow-up of 24 months, we observed an overall hernia recurrence rate of 4.0%, and an overall complication rate of 34%. Tension-free primary fascial repair and mesh repair of tension defects had equivalent recurrence rates (3.3% vs. 5%) and complication rates (40% vs. 25%). Repairs buttressed with flaps and repairs without buttressing had equivalent recurrence rates (3% vs. 6%) and complication rates (38% vs 28%). Repairs with and without body contouring techniques as part of the reconstructive plan had equivalent recurrence rates (7.7% vs. 0%) and complication rates (31.7% vs. 53%). Mean patient satisfaction was 4.8 of 5. Reconstruction of complex and recurrent hernias can be successfully performed. When tension-free primary fascial closure is not possible, an inlay mesh with a soft-tissue buttress leads to a 10-fold reduction in hernia recurrence as compared to historical norms. Concomitant body contouring surgery does not impact recurrence or complication rates and may contribute to reconstructive success.
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PMID:A "buttressed mesh" technique for fascial closure in complex abdominal wall reconstruction. 1924 May 26

We evaluated the incidence of and predisposing factors for an incisional hernia after kidney transplantation. Numerous techniques have been used to repair postoperative fascial dehiscences or simple incisional hernias, but no clear treatment exists for giant hernias. Our aim was to obtain (1) a safe procedure to repair a large abdominal defect and reinforce the surrounding, fragile zones and (2) a simple, rapid technique to reduce the operative time. Herein we have described the surgical repair of a giant incisional hernia using intraperitoneal Gore ePTFE dual-mesh plus (Gore-Tex; W. L. Gore, Flagstaff, Ariz, USA) in a 55-year-old man status-post renal transplantation. Total necrosis of distal graft ureter had caused a giant urinoma. The patient was reexplored on day 2 posttransplantation with a primary fascial approximation. Thirty days after transplantation we discovered a large incisional hernia and performed a repair. No drain was used. The patient continued immunosuppressive therapy (cyclosporine, mycophenolate mofetil, prednisolone) and was discharged on postoperative day 4 with no complications. An ultrasonographic follow-up at 1 year revealed the prosthesis to be correctly positioned. Incisional hernia is not rare after renal transplantation but the real incidence is unknown. Immunosuppressive therapy, prolonged pretransplantation dialysis, obesity, and diabetes are probably the major causes of incisional hernias in these patients. Surgical complications of renal transplantation surgery, such as wound hematoma, urinoma, and lymphocele, are the most important predisposing factors for an incisional hernia. The use of intraperitoneal ePTFE dual-mesh is feasible, safe, and easy to repair a large incisional hernia in a kidney transplant patient.
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PMID:Use of intraperitoneal ePTFE Gore dual-mesh plus in a giant incisional hernia after kidney transplantation: a case report. 1946 May 70

Surgery as a treatment modality for morbid obesity has shown impressive progress over the past decades because of a better understanding of the metabolic characteristics of obesity and the rationale for its surgical treatment. Biliopancreatic diversion was first performed in humans in 1976. Since then it has been an excellent operation for morbid obesity to achieve long-term weight reduction. We present our laparoscopic biliopancreatic diversion protocol, with or without distal gastrectomy (Resa's operation). From 1995 to October 2008 we operated on 201 patients; open biliopancreatic diversion was performed in 48 patients, while the remaining patients underwent laparoscopic biliopancreatic diversion (84 laparoscopic Scopinaro's operations, 69 laparoscopic Resa's operations). The mean operating time was 140 minutes for the open procedures, 180 minutes for Scopinaro's laparoscopic operation and 135 minutes for Resa's laparoscopic operation. The mean postoperative stay was 5.5 days. Our mortality rate consisted of two patients (0.99%) who had pulmonary embolisms. Other major complications were three cases of leakage from the jejuno-ileal anastomosis, 18 cases of incisional hernia, 6 cases of metabolic diseases; 1 case of acute hepatitis and 1 case of bronchopneumonia. Biliopancreatic diversion can be performed satisfactorily by laparoscopy. A factor that may reduce the technical difficulties and make the technique totally reversible is the gastric sparing. Thus an upper digestive endoscopy can determine preoperatively whether the patient will need a gastrectomy, depending on its results.
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PMID:Laparoscopic biliopancreatic diversion: our preliminary experience with 201 consecutive cases. 1953 86

Ambulatory hernia surgery under local anesthesia is becoming more widely used worldwide. Although many reports include obese patients, there are no studies that report specifically on the feasibility and safety of ambulatory hernia surgery in this category of patients. This paper documents our experience in this respect. The present investigation is an observational study performed at the CRS Hernia Center, Santiago, Chile, on 510 obese and 1,521 non-obese patients with all kinds of hernias susceptible to ambulatory hernia repair under local anesthesia. Both tissue and mesh repairs were performed. Obesity was defined as a body mass index (BMI) greater than 30. Patients with a BMI greater than 45 were excluded from this study. Operative time and pain experienced during the intervention were recorded. During the controls performed by a staff member at the 7th postoperative day, a questionnaire was answered by each patient regarding satisfaction, complaints, and postoperative pain. A second questionnaire was completed on the 30th postoperative day. Satisfaction and pain were both measured by means of a 10-point visual analog scale (VAS). The mean age was similar in both groups (51 years for non-obese and 52 years for obese patients). Obesity was present in 38.3% of women and in 17.5% of men (P < 0.002). Diabetes and hypertension were observed in a significantly (P < 0.004 and P < 0.02, respectively) higher proportion of obese patients. The duration of the operation on obese patients was 78 min compared with 62 min in non-obese patients (P < 0.001). Pain experienced during the intervention was significantly higher in obese patients with a VAS of 2.4 vs. in lean patients with a VAS of 2.0 (P < 0.01). At 24 h, pain was significantly higher and satisfaction significantly lower in obese patients (P < 0.007 and P < 0.0001, respectively). All other parameters were similar in both groups. At 30 days, infection was present in 0.7% of lean patients and in 2.1% of obese patients (P < 0.02). The frequency of hematomas, funicular swelling, and pain was similar in both groups. We conclude that ambulatory abdominal wall hernia repair under local anesthesia is feasible in obese patients. Because of the increased length of surgery in these patients, monitored sedation and prophylactic antibiotic cover should be used. The slight decrease in patient satisfaction is balanced by the lower risks and higher costs associated with full general anesthetic.
Hernia 2010 Feb
PMID:Ambulatory hernia surgery under local anesthesia is feasible and safe in obese patients. 1986 90

Carpenter syndrome (Acrocephalopolysyndactyly type II) is a rare disorder characterized by acrocephaly, mental retardation, congenital heart disease, syndactyly, preaxial polydactyly, obesity, cryptorchidism, hypogenitalism, bony abnormalities, and umbilical hernia. We present a case of unexpected death of a 7-year-old boy with Carpenter Syndrome complicated by twin and premature birth as well as repaired congenital heart disease.
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PMID:Sudden death in a child with Carpenter Syndrome. Case report and literature review. 1992 77

Exercise therapy is generally recommended in osteoarthritis (OA) of the hip or knee. However, coexisting disorders may bring additional impairments, which may necessitate adaptations to exercise for OA of the hip or knee. For the purpose of developing an adapted protocol for exercise therapy in OA patients with coexisting disorders, information is needed on which specific coexisting disorders in OA are associated with activity limitations and pain. To describe the relationship between specific coexisting disorders, activity limitations, and pain in patients with OA of the hip or knee, a cross-sectional cohort study among 288 older adults (50-85 years of age) with OA of hip or knee was conducted. Subjects were recruited from three rehabilitation centers and two hospitals. Demographic data, clinical data, information about coexisting disorders (i.e., comorbidity and other disorders), activity limitations (WOMAC: physical functioning domain), and pain (visual analogue scale (VAS)) were collected by questionnaire. Statistical analysis included descriptive statistics and multivariate regression analysis. Coexisting disorders associated with activity limitations were chronic back pain or hernia, arthritis of the hand or feet, and other chronic rheumatic diseases (all musculoskeletal disorders); diabetes and chronic cystitis (non-musculoskeletal disorders); hearing impairments in a face-to-face conversation, vision impairments in long distances, and dizziness in combination with falling (all sensory impairments); and overweight and obesity. Coexistent disorders associated with pain were arthritis of the hand or feet, other chronic rheumatic diseases (musculoskeletal disorders), and diabetes (non-musculoskeletal disorder). Specific disorders coexisting next to OA and associated with additional activity limitations and pain were identified. These coexisting disorders need to be addressed in exercise therapy and rehabilitation for patients with OA of the hip or knee.
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PMID:Osteoarthritis of the hip or knee: which coexisting disorders are disabling? 2017 25

Definitive repair of recurrent ventral hernias using abdominal wall reconstruction techniques is an essential tool in the armentarium for general and plastic surgeons. Despite the great morbidity associated with incisional hernia, no consensus exists on the best means for treatment (Korenkov et al, Langenbecks Arch Surg. 2001;386:65-73). Ramirez et al (Plast Reconstr Surg. 1990;83:519-526) describes the "component separation" technique to mobilize the rectus-abdominus internal oblique and external oblique flap to correct the defect. This retrospective institutional study reviewed 10 years of myofascial flap reconstruction from 1996 to 2006 at Thomas Jefferson University Hospital and revealed an 18.3% recurrence rate in 545 component separations. We identified obesity (body mass index >30 kg/m2), age >65 years old, male gender, postoperative seroma, and preoperative infection as risk factors for hernia recurrence.
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PMID:Synthetic and biological mesh in component separation: a 10-year single institution review. 2039 90

Bariatric surgery is a safe and most effective method of achieving substantial long-term weight loss. Surgery should be considered in case of all patients with a BMI of more than 40 kg/m2 and for those with a BMI of over 35 kg/m2 with obesity-related co-morbidities, after conventional treatment failure. The most frequently used procedures in surgical treatment of obesity performed mostly laparoscopically are restrictive operations limiting energy intake by reducing gastric capacity (vertical banded gastroplasty adjustable gastric band, sleeve gastrectomy) and restrictive/ malabsorptive surgeries also inducing decreased absorption of nutrients by shortening the functional length of the small intestine (Roux-en-Y gastric bypass). Frequent complications following surgery may include hyperemesis, intragastric band migration, gastric perforation, nutritional deficiencies, anastomotic leak, bleeding, anastomotic stricture, internal hernia, wound infection. It is generally recommended for women after bariatric surgery to wait approximately at least 12 months before becoming pregnant. There exists considerable threat that rapid weight loss (relative starvation phase) may be unhealthy for a mother and a baby. Pregnancy after weight loss surgery is not only safe for the mother and the baby but may also be less risky than pregnancy in morbidly obese patients. Postoperative nutrient supplementation and close supervision before, during, and after pregnancy adjusted to individual requirements of a woman can help to prevent nutrition-related complications such as deficiencies in iron, vitamin A, vitamin B12, vitamin K, folate and calcium, and improve maternal and fetal health.
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PMID:[Obesity among women. Pregnancy after bariatric surgery: a qualitative review]. 2048 45


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