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 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Laparoscopic cholecystectomy is a minimally invasive procedure whereby the gallbladder is removed using laparoscopic techniques. The indications are similar to those for elective traditional cholecystectomy, but selection of patients is important for success. Contraindications are currently evolving. Patients with advanced cholecystitis, abdominal sepsis, ileus, bleeding disorders, pregnancy, and morbid obesity should not undergo this procedure. The procedure requires good traditional surgical skills, as well as additional laparoscopic (and laser) skills. Operative time is slightly longer than for traditional cholecystectomy, but decreases with experience. Morbidity is low, but there is a concern about bile duct injuries. Mortality is very low (0%) and is comparable to traditional cholecystectomy (0.4%). The major advantages of laparoscopic cholecystectomy are the short hospital stay (average: 2 days) and early return to normal activity (7 days). This results in a reduction in hospital costs. Adequate training and credentialing are important processes to foster good patient outcomes.
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PMID:Traditional versus laparoscopic cholecystectomy. 182 53

Patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications. To evaluate outcome following revisional procedures, we reviewed the records of 32 such patients treated at UCLA between April 1986 and May 1989. Twenty-five women (78%) and 7 men (22%) with a mean age of 44 years underwent 76 reoperations (2.4 per patient) for complications of prior obesity surgery. Indications for initial surgical revision consisted primarily of metabolic derangements (12 patients) and weight-related problems (11 patients). In contrast, indications for the patients' final surgical procedure were commonly for bowel obstruction (41%), intra-abdominal sepsis (12%), and gastrointestinal bleeding (6%). Following initial revision, 23 patients (71.8%) required further surgery for major complications and four patients died (12.5%). While initial revisions are frequently indicated for metabolic problems, final reoperations are more frequently undertaken for urgent, life-threatening complications. Revisional procedures for morbid obesity should be carefully considered, and the potential for major complications and/or death should be weighted heavily against proposed benefits.
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PMID:Reoperative surgery for the morbidly obese. A university experience. 222 81

Of 72 patients who underwent jejunoileal bypass because of morbid obesity, 69 could be evaluated with special reference to long-term (median 11 years) results. One of the other three had fatal anastomotic leakage, one underwent resection and reversal of shunt because of postoperative gangrene in the bypassed segment, and one died of sepsis and liver failure following cholecystectomy 6 months after bypass. The median body mass index (kg/m2) fell from 45.4 preoperatively to 33.2 after 16 years. Shunt-related complications in early and late follow-up were diarrhoea (n = 15), anal/perianal disorders (15), arthralgia (15), urinary calculi (16), cholelithiasis (5), severe flatulence (7), liver cirrhosis (5), intestinal tuberculosis (1), ileitis (1), severe electrolyte disturbance (4), hypomagnesaemia (22), hypokalaemia (8), and deficiency of vitamin B12 (24), iron (24) and folate (17). Although jejunal bypass effectively reduces weight, the patients are at continuous risk of many complications. However, the improvement in quality of life should not be underestimated.
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PMID:Jejunoileal bypass for morbid obesity. Report of a series with long-term results. 259 48

A characteristic intermittent neutrophilic dermatosis, associated with polyarthritis, tenosynovitis, malaise, fever, and cryoglobulinemia, occurs in 20% of patients who undergo ileojejunal bypass surgery for the treatment of morbid obesity. The clinical syndrome may mimic gonococcal sepsis. The histologic changes in the skin are those of Sweet's syndrome. The syndrome remits spontaneously in most cases, but it may recur intermittently over a period of years. Treatment with low-dose steroids, tetracycline, or metronidazole suppresses symptoms in most cases, and restoration of normal bowel anatomy is curative. Skin testing with Streptococcus pyogenes antigen causes an excerbation of symptoms, or may provoke the entire syndrome de novo. Bacterial peptidoglycans, especially those of group A streptococci, produce similar arthritis and skin lesions in animal models. Peptidoglycans from numerous intestinal bacteria share common structural and antigenic features with S. pyrogenes peptidoglycan and are suggested as causative of the toxic and immunologic features of this syndrome.
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PMID:The bowel bypass syndrome: a response to bacterial peptidoglycans. 740 Apr 4

A total of 325 patients, aged 80 to 92 (mean 82), underwent cardiac operations with cardiopulmonary bypass over a 4-year period (1991-1995). Hypothermia (22 degrees C) and hyperkalemic cardioplegia were used in each. Coronary bypass procedures only (Group I) were performed in 255 patients with 22 early deaths (8.6%), and the average number of grafts was 3.7 per patient. Single or double valve replacement, with coronary bypass (Group II) was performed in 46 patients, with six early deaths (13%). Single or double valve replacement, without coronary bypass (Group III) was performed in 24 patients, with two early deaths (8.3%). Total hospital mortality was 30 deaths in 325 patients (9.2%). Fifty-six procedures (22%) from Group I and four (9%) from Group II were performed as emergencies, and all operations in Group III were elective. Seventy-two patients (27%) from Group I, 18 patients (39%) from Group II, and nine patients (37%) from Group III had major complications including renal failure, cerebrovascular accident, myocardial infarction, postoperative hemorrhage, sepsis, and ventilatory dependency. Mean hospital stay was 10.5 days for Group I, 13.3 days for Group II, and 15.2 days for Group III, with an overall mean of 13 days (range, 6-52) days. Higher mortality was related to a cardiac index <1.8, cardiogenic shock, emergency operation, creatinine >2.0, and morbid obesity. Mean left ventricular ejection fractions were 0.51 for Group I, 0.45 for Group II, and 0.49 for Group III. Preoperative risk factors associated with a higher mortality included hypertension, smoking, diabetes, and pulmonary hypertension. Two hundred seventy-two of the 299 operative survivors were followed for a mean of 18 (range, 3-52) months. The actuarial survival of octogenarians is 92 per cent, 80 per cent, and 65 per cent at 1, 3, and 5 years, respectively, and of the patients surviving operation it was 85 per cent, 70 per cent, and 55 per cent at 1, 3, and 5 years, respectively. At postoperative follow up, 80 per cent of the survivors reported an active functional status, and there was a low incidence of cardiac-related deaths.
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PMID:Coronary artery bypass and valve replacement in octogenarians. 889 18

Spontaneous and progressive dermatoliponecrosis and panniculitis is an unusual complication of morbid obesity. A fatal case is reported, and the term eutrophication is suggested as an appropriately descriptive name for this intractable condition. A 45-year-old grossly morbidly obese female (weighing 286.4 kg) presented with spontaneous necrosis of skin and fat-folds of the abdomen, trunk, and thighs. She also had congestive cardiac failure, respiratory insufficiency and anemia. Congestive cardiac failure and anemia were treated aggressively. However, all attempts at control of the superficial tissue necrosis and the supervening infection failed. Superficial gangrene and putrefaction of the fat-folds progressed relentlessly, and death finally ensued due to sepsis and multiple system failure. The early signs of panniculitis, especially of grossly dependent fat and skin-folds in the morbidly obese must be recognized early and treated with aggressive weight loss, if this potentially fatal complication of morbid obesity is to be avoided.
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PMID:Eutrophication: spontaneous progressive dermatoliponecrosis. A Fatal Complication of Gross Morbid Obesity. 1076 83

Access to the central venous circulation for chemotherapy infusion has traditionally been achieved surgically via the subclavian or jugular routes. With ongoing improvements in technical management, alternative means of central venous access have been developed such as arm-port or forearm-port implantation under imaging guidance. Venous arm port devices implantation was attempted in 200 cancer patients under fluoroscopic guidance, after arm venography. The 4% failure rate was due to the inability to perform the arm venogram, venous spasm or presence of a large contrast medium hematoma (rolling vein). Median follow-up was 180 days (range 4-671) and the complication rate was 13.3% (0.7/1,000 patients-day). Twenty-six complications occurred and were due to venous thrombosis (n = 3), large brachial hematoma (n = 1), local (n = 7) and systemic sepsis (n = 1), skin dehiscence (n = 4), fissuration (n = 4), dislocation (n = 2), obstruction (n = 2), and twist of the port (n = 2), leading to a 8.5% removal rate. Main indications for arm port implantation may be breast cancer, previous arm or cervical venous thrombosis, morbid obesity, respiratory insufficiency, previous surgical failure and the irradiated neck.
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PMID:[Brachial fluoroscopically guided implantation of venous port devices in oncology patients]. 1220 84

This was a retrospective chart review of consecutive obese patients admitted to the medical intensive care unit. Patients were divided into 2 groups: mild to moderately obese (group 1, body mass index =30-40 kg/m(2)) and morbidly obese (group 2, body mass index >40 kg/m(2)). Acute Physiology and Chronic Health Evaluation II scores were not significantly different between the 2 groups. Morbidly obese patients (group 2) had higher rates of mortality and nursing home admission. They also showed higher rates of intensive care unit complications including sepsis, nosocomial pneumonia, acute respiratory distress syndrome, catheter infection, tracheostomy, and acute renal failure. Their median length of mechanical ventilation was longer (2 days, range 2-12 vs 9 days, range 1-37,P = .009). In a logistic regression analysis, morbid obesity remained a significant predictor of death or disposition to nursing home even after controlling for age (P = .019, odds ratio = 7.60, 95% confidence interval = 1.39-41.6). Morbidly obese patients (body mass index >40 kg/m(2)) admitted to intensive care units have higher rates of mortality, nursing home admission, and intensive care unit complications and have longer stays in the intensive care unit and time on mechanical ventilation.
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PMID:Outcome of morbid obesity in the intensive care unit. 1588 2

Mortality has been reported to complicate gastric bypass, with common causes of death attributable to anastomotic leaks, sepsis, hemorrhage, and bowel obstruction. We evaluated autopsy reports from 10 patients having undergone gastric bypass. Medical records were reviewed to identify comorbidities. Data of interest included preoperative electrocardiogram (EKG) abnormalities, cause of death, body weight, anastamosis appearance, heart weight, extent of coronary artery disease, ventricular size, liver weight, and gall bladder status. A total of 7 men and 3 women were autopsied. Average age was 40 years (range, 30-49 years), and mean body mass index at autopsy was 60.3 kg/m(2) (range, 33.2-80.9 kg/m(2)). Evidence of anastomotic leaks was present in 7 cases, resulting in 4 deaths. Death was attributed to pulmonary embolism in one case. There were 5 cardiac-related deaths, all attributed to arrhythmias. Microscopic evidence of coronary artery disease was observed in 6. Cardiomegaly was seen in all patients, left ventricular hypertrophy in 8, right ventricular hypertrophy in 3, and hepatomegaly in all 10. Nine patients were status post cholecystectomy. Of the 8 preoperative EKG available, abnormalities were identified in 5. After gastric bypass, death was attributed to cardiac-related causes, pulmonary embolism, and operative complications. A significant proportion of cardiac-related deaths occured in the absence of atherosclerosis. Most patients had preoperative EKG abnormalities. As a high incidence of cardiomegaly was observed, operative stress associated with the procedure may increase the risk of arrhythmia in morbid obesity. Consequently, in morbidly obese patients, a detailed preoperative cardiovascular evaluation is warranted to reduce postoperative mortality.
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PMID:Postmortem findings in morbidly obese individuals dying after gastric bypass procedures. 1723 34

We report a novel technique for gastro-gastric fistula (GGF) repair. A 44-year-old woman was found to have a fistula between her gastric pouch and bypassed stomach 18 years after Roux-en-Y gastric bypass (RYGBP) for morbid obesity. She underwent an attempted open surgical repair, which was complicated by postoperative abdominal sepsis. An upper gastrointestinal series, abdominal CT scan and upper endoscopy confirmed the diagnosis of failed surgery with recurrent GGF. Under endoscopic and fluoroscopic guidance, two ports were inserted percutaneously into the stomach. The fistula was closed with a percutaneous, transgastric, totally extraperitoneal approach. She remains well 7 months after this intervention. This procedure appears to be a safe and effective minimally invasive approach for closure of GGF after RYGBP. This is the first description of an intragastric, percutaneous closure of a GGF after RYGBP in the medical literature. Further experience with this technique is needed to define the selection criteria, limitations, advantages, and disadvantages.
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PMID:A new approach for treatment of gastro-gastric fistula after gastric bypass. 1747 79


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