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1.  Bariatric emergencies: current evidence and strategies of management 
Background
The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management.
Methods
The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review.
Results
Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01).
Conclusions
Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.
doi:10.1186/1749-7922-8-58
PMCID: PMC3923426  PMID: 24373182
Laparoscopic roux en-Y gastric bypass; Laparoscopic sleeve gastrectomy; Laparoscopic adjustable gastric band; Stomal ulceration
2.  Obstructive jaundice due to autoimmune cholangiopathy 
BMJ Case Reports  2009;2009:bcr11.2008.1291.
A 59-year-old man presented with upper abdominal pain, cholestasis and radiological evidence of common hepatic duct hilar stricture which was suggestive of cholangiocarcinoma. The patient initially underwent percutaneous drainage and a laparotomy. No evidence of malignancy was identified. He was noted to have retroperitoneal fibrosis, which was confirmed on histology. The combination of cholangiopathy and retroperitoneal fibrosis suggested an underlying autoimmune process. Although the investigations did not show any evidence of IgG4 related disease, the combination of a cholangiopathy and retroperitoneal fibrosis is in keeping with autoimmune cholangiopathy and a steroid regimen was commenced. Our patient is now symptom-free with no further episodes of cholangitis. He has commenced azathioprine to maintain long term remission.
doi:10.1136/bcr.11.2008.1291
PMCID: PMC3027632  PMID: 21686376
3.  Can Roux-en-Y gastric bypass provide a lifelong solution for diabetes mellitus? 
Canadian Journal of Surgery  2009;52(6):E269-E275.
Background
The surgical treatment of diabetes had witnessed progressive development and success since the first case of pancreatic transplantation. Although this was a great step, wide clinical application was limited by several factors. Bariatric surgery such as gastric bypass is emerging as a promising option in obese patients with type 2 diabetes. The aim of this article is to explore the current application of gastric bypass in patients with type 2 diabetes and the theoretical bases of gastric bypass as a treatment option for type 1 diabetes.
Methods
We performed a MEDLINE search for articles published from August 1955 to December 2008 using the words “surgical treatment of diabetes,” “etiology of diabetes” and “gastric bypass.”
Results
We identified 3215 studies and selected 72 relevant papers for review. Surgical treatment of diabetes is evolving from complex pancreatic and islets transplantation surgery for type 1 diabetes with critical postoperative outcome and follow-up to a metabolic surgery, including gastric bypass. Gastric bypass (no immune suppression or graft rejection) has proven to be highly effective treatment for obese patients and nonobese animals with type 2 diabetes. There are certain shared criteria between types 1 and 2 diabetes, making a selected spectrum of the disease a potential target for metabolic surgery to improve or cure diabetes.
Conclusion
Roux-en-Y gastric bypass is a promising option for lifelong treatment of type 2 diabetes. It has the potential to improve or cure a selected spectrum of type 1 diabetes when performed early in the disease. Further animal model studies or randomized controlled trials are needed to support our conclusion.
PMCID: PMC2792412  PMID: 20011163
4.  Long-Term Study of Port-Site Incisional Hernia After Laparoscopic Procedures 
Background:
Laparoscopic surgery is widely practiced and offers realistic benefits over conventional surgery. There is considerable variation in results between surgeons, concerning port-site complications. The aim of this study was to evaluate the laparoscopic port closure technique and to explore the factors associated with port-site incisional hernia.
Methods:
Between January 2000 and January 2007, 5541 laparoscopic operations were performed by a single consultant surgeon for different indications. The ports were closed by the classical method using a J-shaped needle after release of pneumoperitoneum. The incidence of port-site incisional hernias was calculated. All patients were followed up by outpatient clinic visits and by their general practitioners.
Results:
During a 6-year period, 5541 laparoscopic operations were performed. Eight patients (0.14%) developed port-site hernia during a mean follow-up period of 43 months (range, 25 to 96) and required elective surgery to repair their hernias. No major complications or mortality was reported.
Conclusion:
Laparoscopic port closure using the classical method was associated with an acceptable incidence of port-site hernia. Modification of the current methods of closure may lead to a new technique to prevent or reduce the incidence of port-site incisional hernias.
PMCID: PMC3015977  PMID: 19793475
Port-site incisional hernia; Pneumoperitoneum; Port closure
5.  Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective 
Introduction
Gastro-oesophageal reflux disease (GORD) is a common problem in the Western countries, and the interest in the minimal access surgical approaches to treat GORD is increasing. In this study, we would like to discuss the presentations and management of complications we encountered after Laparoscopic Nissen's fundoplication in our District General NHS Hospital. The aim is to recognise these complications at the earliest stage for effective management to minimise the morbidity and mortality.
Methods
301 patients underwent laparoscopic treatment for GORD by a single consultant surgeon in our NHS Trust from September 1999. The data was prospectively collected and entered into a database. The data was retrospectively analysed for presentations for complications and their management.
Results
Surgery was completed laparoscopically in all patients, except in five, where the operation was technically difficult due to pre-existing conditions. The complications we encountered during surgery and follow-up period were major intra-operative bleeding (n = 1, 0.33%), severe post-operative nausea and vomiting (n = 1, 0.33%), wound infection (n = 3, 1%), port-site herniation (n = 1, 0.33%), wrap-migration (n = 2, 0.66%), wrap-ischaemia (n = 1, 0.33%), recurrent regurgitation (n = 4, 1.32%), recurrent heartburn (n = 29, 9.63%), tension pneumothorax (n = 2, 0.66%), surgical emphysema (n = 8, 2.66%), and port-site pain (n = 4, 1.33%).
Conclusion
Minimal access approach to treat GORD has presented with some specific and unique complications. It is important to recognise these complications at the earliest possible stage as some of these patients may present in an acute setting requiring emergency surgery. All members of the department, and not just the members of the specialised team, should be aware about these complications to minimise the morbidity and mortality.
doi:10.1186/1750-1164-3-1
PMCID: PMC2644311  PMID: 19193220
6.  Patient Experience With Gallstone Disease in a National Health Service District Hospital 
Background:
The prevalence of gallstone disease in the community makes it an important area of service in district general hospitals. Laparoscopic surgical techniques in synergy with modern imaging and endoscopic and interventional techniques have revolutionized the treatment of gallstone disease, making it possible to provide prompt and definitive care to patients.
Methods:
Patients with gallstone disease were treated based on a predetermined protocol by a special-interest team depending on the patient's mode of presentation. Data were collected and analyzed prospectively.
Results:
Our team treated 1332 patients with gallstone disease between September 1999 and December 2007. Patients (249) with acute symptoms presented through Accident and Emergency (A&E). Despite varied presentations, laparoscopic treatment was possible in all but 8 patients. The study comprised 696 patients who underwent laparoscopic cholecystectomy (LC) as in-hospital (23 hour) cases in a stand-alone center, and 257 outpatients and 379 inpatients. Sixty-seven patients with acute cholecystitis had their surgery within 96 hours of acute presentation. Seventy patients had laparoscopic subtotal cholecystectomy. The overall morbidity was 2.33% with 3 patients having residual common bile duct stones; 3 patients had biliary leak from cystic or accessory duct stumps and one had idiopathic right segmental liver atrophy; 19 had wound infections, 5 had port-site hernia. No mortalities occurred during the 30-day follow-up.
Conclusion:
We believe that prompt investigation with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method for treating gallstone disease in district general hospitals. Our experience with over 1000 patients has offered us the courage of conviction to say that justice is finally here for gallstone sufferers.
PMCID: PMC3016000  PMID: 19275855
Gallstones; Cholecystectomy; Laparoscopic
7.  Portal vein gas in emergency surgery 
Background
Portal vein gas is an ominous radiological sign, which indicates a serious gastrointestinal problem in the majority of patients. Many causes have been identified and the most important was bowel ischemia and mesenteric vascular accident. The presentation of patients is varied and the diagnosis of the underlying problem depends mainly on the radiological findings and clinical signs. The aim of this article is to show the clinical importance of portal vein gas and its management in emergency surgery.
Methods
A computerised search was made of the Medline for publications discussing portal vein gas through March 2008. Sixty articles were identified and selected for this review because of their relevance. These articles cover a period from 1975–2008.
Results
Two hundreds and seventy-five patients with gas in the portal venous system were reported. The commonest cause for portal vein gas was bowel ischemia and mesenteric vascular pathology (61.44%). This was followed by inflammation of the gastrointestinal tract (16.26%), obstruction and dilatation (9.03%), sepsis (6.6%), iatrogenic injury and trauma (3.01%) and cancer (1.8%). Idiopathic portal vein gas was also reported (1.8%).
Conclusion
Portal vein gas is a diagnostic sign, which indicates a serious intra-abdominal pathology requiring emergency surgery in the majority of patients. Portal vein gas due to simple and benign cause can be treated conservatively. Correlation between clinical and diagnostic findings is important to set the management plan.
doi:10.1186/1749-7922-3-21
PMCID: PMC2490689  PMID: 18637169
8.  An unusual cause of gastric outlet obstruction during percutaneous endogastric feeding: a case report 
Introduction
The differential diagnoses of acute abdomen in children include common and rare pathologies. Within this list, different types of bezoars causing gastrointestinal obstruction have been reported in the literature and different methods of management have been described. The aim of this article is to highlight a rare presentation of lactobezoars following prolonged percutaneous endoscopic gastrostomy feeding and its successful surgical management.
Case presentation
A 16-year-old boy was admitted to a paediatric ward with abdominal distension and high output from his permanent gastrostomy feeding tube, with drainage of bilious fluids. The clinical, radiological and endoscopical examinations were suggestive of partial duodenal obstruction with multiple bezoars in the stomach and duodenum. Gastrojejunostomy was performed after the removal of 14 bezoars. The child had an uneventful postoperative course and was discharged on the sixth postoperative day in a stable condition.
Conclusion
Lactobezoars should be included in the differential diagnosis of acute abdominal pain in patients with percutaneous endogastric feeding. Endoscopy is important in making the diagnosis of this surgical condition of the upper gastrointestinal tract in a child.
doi:10.1186/1752-1947-2-199
PMCID: PMC2432065  PMID: 18547437
9.  Complicated diverticular disease of the colon, do we need to change the classical approach, a retrospective study of 110 patients in southeast England 
Background
Complicated diverticular disease of the colon imposes a serious risk to patient's life, challenge to surgeons and has cost implications for health authority. The aim of this study is to evaluate the management outcome of complicated colonic diverticular disease in a district hospital and to explore the current strategies of treatment.
Methods
This is a retrospective study of all patients who were admitted to the surgical ward between May 2002 and November 2006 with a diagnosis of complicated diverticular disease. A proforma of patients' details, admission date, ITU admission, management outcomes and the follow up were recorded from the patients case notes and analyzed. The mean follow-up was 34 months (range 6–60 months)
Results
The mean age of patients was 72.7 years (range 39–87 years). Thirty-one men (28.18 %) and Seventy-nine women (71.81%) were included in this study. Male: female ratio was 1:2.5.
Sixty-eight percent of patients had one or more co-morbidities. Forty-one patients (37.27%) had two or more episodes of diverticulitis while 41.8% of them had no history of diverticular disease.
Eighty-six percent of patients presented with acute abdominal pain while bleeding per rectum was the main presentation in 14%. Constipation and erratic bowel habit were the commonest chronic symptoms in patients with history of diverticular disease. Generalized tenderness was reported in 64.28% while 35.71% have left iliac fossa tenderness. Leukocytosis was reported in 58 patients (52.72%).
The mean time from the admission until the start of operative intervention was 20.57 hours (range 4–96 hours). Perforation was confirmed in 59.52%. Mortality was 10.90%. Another 4 (3.63%) died during follow up for other reasons.
Conclusion
Complicated diverticular disease carries significant morbidity and mortality. These influenced by patient-related factors. Because of high mortality and morbidities, we suggest the need to target a specific group of patients for prophylactic resection.
doi:10.1186/1749-7922-3-5
PMCID: PMC2246106  PMID: 18218109
10.  An apricot story: view through a keyhole 
Background
Very few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy.
Case presentation
A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy.
Discussion
Small bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods.
Conclusion
Generally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach.
doi:10.1186/1749-7922-2-20
PMCID: PMC1976312  PMID: 17697369
11.  Agenesis of the Gallbladder: Lessons to Learn 
Background:
Congenital absence of the gallbladder is a rare, usually asymptomatic, anatomical variation. Some affected individuals may present with a clinical picture suggestive of gallbladder disease. This presentation, coupled with the inability of standard abdominal ultrasonography to convincingly diagnose agenesis of the gallbladder, can put the surgeon in a diagnostic and intraoperative dilemma.
Case Report:
A 30-year-old lady presenting with clinical features of cholecystitis and diagnosed with shrunken gallbladder on ultrasonography was scheduled for laparoscopic cholecystectomy. Intraoperatively, the gallbladder could not be seen even after thorough dissection in the region of the porta hepatis. The procedure was terminated at this stage, and further imaging of the extrahepatic biliary system by magnetic resonance cholangiopancreatography and endoscopic ultrasound confirmed the diagnosis of congenital absence of the gallbladder.
Conclusion:
Nonvisualization of the gallbladder at laparoscopy, in the absence of any other diagnosed biliary disorder, need not prompt conversion to open exploration of the extrahepatic biliary system. Newer imaging modalities are relatively noninvasive and can provide good delineation of biliary anatomy. This allows well-planned treatment and at the same time prevents the added morbidity of a diagnostic laparotomy performed solely to confirm the absence of the gallbladder.
PMCID: PMC3015765  PMID: 17575771
Gallbladder; Absence; Congenital; Laparoscopy
12.  Gallstones: Best Served Hot 
Background:
Acute episodes of gallstone-related diseases have traditionally been managed conservatively. In the event of gallstones obstructing the common bile duct, patients had endoscopic extraction of calculi with interval cholecystectomy after 4 weeks to 6 weeks when acute inflammatory changes have subsided. This placed the patient at risk of recurrent cholecystitis, pancreatitis, or other complications of cholelithiasis.
Methods:
Patients presenting with acute gallstone-related diseases were investigated and underwent laparoscopic cholecystectomy during the same admission according to a predetermined treatment protocol.
Results:
All patients (119) treated according to the study protocol had good results, with no 30-day mortality and no biliary tract injuries. One patient had bleeding from the cystic artery, and 6 patients required conversion to open cholecystectomy.
Conclusion:
Growing expertise in laparoscopic cholecystectomy has made it possible for surgeons to perform safe cholecystectomy in the presence of acute gallstone-related disease. Our experience of managing gallstone disease with prompt cholecystectomy during the index admission shows that this approach provides better, safer, and more cost-effective patient care.
PMCID: PMC3015704  PMID: 17212890
Gallstones; Acute disease; Laparoscopic cholecystectomy
13.  Outcome and Patient Acceptance of Outpatient Laparoscopic Cholecystectomy 
Objective:
The aim of this prospective study was to evaluate patients' experience and the outcome of outpatient laparoscopic cholecystectomy performed by a single upper gastrointestinal surgeon at a district hospital.
Methods:
Between November 1999 and May 2003, 100 patients underwent outpatient laparoscopic cholecystectomy. Patients were followed up at 2 weeks as outpatients, and a questionnaire was mailed to all patients to assess their experiences.
Results:
None of the patients required conversion to open cholecystectomy. One patient required admission to the hospital following drain insertion, and one patient was readmitted for pain control. One patient developed an epigastric port infection that resolved with antibiotics. Sixty-eight of the 100 patients completed the postal questionnaire. Thirty-five patients rated their overall experience as excellent. Twenty-three patients experienced very mild or no pain. All patients' right upper quadrant pain subsided or improved following surgery except one patient who stated that it became worse. Sixty-three patients (92.7%) stated they would recommend outpatient laparoscopic cholecystectomy to a friend or relative.
Conclusion:
Laparoscopic cholecystectomy can be performed safely as an outpatient procedure with a high acceptance and satisfaction rate in select patients.
PMCID: PMC3016801  PMID: 15347113
Laparoscopic cholecystectomy; Outpatient procedure; Morbidity

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