2005 SAGES Abstracts

POSTER ABSTRACTS
SAGES 2005
sumed concentric or eccentric gastric prolapse. At that time,
all patients were found to have moderate to large crural defect
requiring 1 to 2 figure-of-eight sutures. Ten underwent posterior
crurapexy and 2 underwent anterior crurapexy. Eleven
patients experienced resolution of GERD without antireflux
medication. One patient redeveloped GERD symptoms due to
recurrent HH and pouch dilatation.
Severe GERD after LAGB is caused by HH. Radiographic examination
may not reflect diagnosis. Symptoms of GERD appear
to be the only reliable indication of HH.
P036–Bariatric Surgery
IMPROVED WOUND INFECTION RATES WITH ROUTINE SUB-
CUTANEOUS PORT SITE DRAINAGE IN LAPAROSCOPIC
ROUX-EN-Y GASTRIC BYPASS, Rashad Choudry MD, Jocelyn
Ho MD,Jennifer Denne MD,Dawn Stepnowski
CRNP,Christopher Kowalski MD, Temple University Hospital,
Philadelphia, PA
Laparoscopic Roux-En-Y Gastric Bypass (LGBP) is a safe and
effective approach in the treatment of morbid obesity.
Technical modifications of the procedure include the trans-oral
passage of the circular stapler anvil (25mm EEA, United States
Surgical) via a modified Salem sump tube for the creation of
the gastrojejunostomy. Port site wound infection at the
retrieval site of the trans-oral placement device, the left subcostal
port site (LSPS), is a recognized complication of this
technique. In addition, this is the site into which the EEA is
inserted to create the gastrojejunostomy.
We aimed to study the incidence of LSPS wound infection in
patients receiving LGBP with and without the use of a subcutaneous,
wound drain.
A review of all patients who underwent a LGBP with trans-oral
passage of the EEA anvil was performed. The incidence LSPS
wound infection was compared in those patients receiving
subcutaneous wound drainage at wound closure versus those
closed without drainage. 83 consecutive patients underwent a
LGBP. 35 patients did not have a subcutaneous drain. 48
patients had a LSPS drain for 24 hours. All patients received
pre and post-operative antibiotic prophylaxis. All port sites
were closed with staples.
The average age of all patients was 42 years (undrained 45;
drained 40). The average BMI for all patients was 50.3
(undrained 48; drained 52). Gender distribution was equal with
a predominance of women in both groups (undrained 86%;
drained 85%). Co-morbid conditions were equally represented
across both groups. Operative time was less than 120 minutes
for all patients. In the undrained group, the incidence of LSPS
infection was 29% (10/35). In the drained group, the incidence
of LSPS infection was 4% (2/48). Analysis of those patients
developing wound infection in both groups revealed no significant
confounding variables. Each cohort had one patient with
diabetes. All 12 patients who developed LSPS infection were
treated with incision and drainage along with oral antibiotics.
Routine use of a subcutaneous LSPS drain for 24 hours significantly
decreases the incidence of infection. The development
of LSPS wound infection is likely related to contamination with
oral and gastric fluid delivered to the site along with the transoral
placement device. The drain appears to disperse the seroma
that often forms at port sites in morbidly obese patients,
eliminating a potential culture environment.
P037–Bariatric Surgery
INTERNAL HERNIA FOLLOWING ROUX-EN-Y GASTRIC
BYPASS: ACCURACY OF DIAGNOSTIC TESTING, Jonathan S
Chun MD, Karen M Flanders MS,Tanya Brown,Paresh Shah
MD,David M Brams MD, Lahey Clinic Medical Center
Introduction: Internal hernia is a well-known potential complication
following Roux-en-Y gastric bypass. The diagnosis is a
clinical one, and radiologic studies and laboratory values are
frequently unhelpful. High index of suspicion and low threshold
for operative exploration are critical in making the diagnosis.
Methods: From 2000 to 2004, 360 Roux-en-Y gastric bypasses
have been performed at LCMC. The twelve patients who subsequently
developed internal hernia requiring re-operation
were reviewed, looking specifically at clinical presentation,
white blood cell count, radiologic studies, and operative find-
134 http://www.sages.org/
ings. Ten patients were post-laparoscopic gastric bypass, two
patients were post-open gastric bypass.
Results: Patients presented three months to two years following
Roux-en-Y gastric bypass. All reported crampy abdominal
pain, with six patients reporting nausea and emesis. Postbypass
weight loss ranged from ninety to two hundred
pounds. White blood cell count was elevated in one patient.
Four patients had CT scan or abdominal plain films showing
dilated stomach or small bowel. Radiologic studies were unremarkable
in the remaining patients.
Eight patients underwent diagnostic laparoscopy, with the
remaining patients undergoing exploratory laparotomy. Eleven
patients were found to have an internal hernia, with two
patients having Peterson?s hernias. One patient had a gastric
volvulus around a previous gastrostomy tube site. No patients
were found to have ischemic bowel or stomach, and none
required bowel resections.
Conclusion: Internal hernia following Roux-en-Y gastric bypass
is a potentially difficult diagnosis to make. Clinical symptoms
and radiologic studies are often non-specific, and laboratory
values are often normal. To avoid bowel compromise, prompt
diagnosis based on a high index of suspicion and a low
threshold for laparoscopic or open exploration is critical.
P038–Bariatric Surgery
LAPAROSCOPIC VERSUS OPEN ROUX-EN-Y GASTRIC
BYPASS AFTER FAILED OPEN VERTICAL BANDING GASTRO-
PLASTY, Joy Collins MD, F Qureshi MD,L Velcu MD,P Thodiyil
MD,B Lane MD,P Yenumula MD,T Rogula MD,B Sacks MD,D
Taylor RN,S Mattar MD,P Schauer MD, University of Pittsburgh
Introduction: Previous reports have demonstrated that failure
after vertical gastric banding (VBG) can be effectively treated
by conversion to Roux-en-Y gastric bypass (RYGBP). Although
laparoscopic principles have been applied to this operation,
the potential benefits of this approach are unknown. Methods:
A retrospective chart review was utilized to study the incidence
of complications in all patients who underwent conversion
surgery from 1999 to 2004. Comparisons were made
between the laparoscopic and open patient groups. Chi-square
test was used for statistical analysis. Results: There were 41
patients with a median age of 51 years (range 33 to 71 years)
who underwent revision surgery. Mean BMI at revision was 47
kg/m2 (range 22 to 69 kg/m2). The most common indications
for conversion after VBG were weight loss failure (76%) and
reflux symptoms (33%). Eighteen operations (44%) were completed
laparosopically, while the remaining 23 (56%) were
done in an open fashion. Early complications occurred in 13 of
41 patients (32%). Seven gastrojejunal anastomotic leaks
occurred, with 4 of these in the laparoscopic conversion group
and 3 in the open conversion group (p=1.00). Three patients
who had open operations developed early strictures at the
gastrojejunostomy anastomosis requiring balloon dilatation,
and one patient developed adhesive small bowel obstruction.
One patient in each group developed a marginal ulcer that was
treated medically. One patient in the laparoscopic group developed
a port-site hernia that was repaired laparoscopically,
while ventral hernia occurred in 30% of patients in the open
conversion group. Conclusions: The laparoscopic approach to
conversion from VBG to Roux-en-Y gastric bypass is a valid
option associated with a similar early complication profile to
the open approach, but with less incidence of ventral hernia
formation.
P039–Bariatric Surgery
LAPRA-TY APPLICATION ON LAPAROSCOPIC GASTRIC
BYPASS SURGERY,AN ALTERNATIVE TO KNOT TYING, Shyam
L. Dahiya,M.D., MBA, Stephen J. McColgan, M.D.,MBA,
Amelia M. Barcenas, BSN, Bellflower Medical Center
Since the 1980’s laparoscopic procedures have become commonplace
in day-to-day surgery. The most prevalent being
laparoscopic cholecystectomy. This procedure requires clip
application not sewing. More advanced procedures such as
laparoscopic nissen fundoplication require a minimal amount
of sewing, where as laparoscopic gastric bypass requires a lot
of sewing. Procedures like this, which require a lot of sewing,
have stayed out of the mainstream and are limited to only
highly skilled surgeons.