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1.  Hypoplasia of the Spleen: Review of Pathogenesis, Diagnosis, and Potential Clinical Implications 
Splenic aplasia is seen when the spleen is congenitally absent, has been surgically removed, or becomes atrophic secondary to episodes of arterial/venous occlusion, which result in splenic infarction. This rare condition is caused by a heterogenous group of diseases, which may present a wide spectrum of clinical manifestations. Splenic hypoplasia is defined as reduction in splenic mass and or functions caused by incomplete splenic development or secondary parenchymal involution. Splenic infarction may be clinically silent and only discovered incidentally during abdominal exploration for other conditions.
Case Report:
We present an unusual case of hypoplastic spleen with calcifications, which was preoperatively found during radiologic workup for gastric carcinoma. An 88-year-old woman presented with coffee-ground emesis. Her past medical history was only significant for atrial fibrillation. Esophagogastroduodenoscopy demonstrated gastric carcinoma, for which a subtotal gastrectomy was planned. Preoperative computed tomography scan showed a hypoplastic spleen with calcifications in the left upper quadrant. Symptoms of immunologic deficiency were not present. During laparotomy, an atrophied and calcified spleen was identified and left in situ. The patient made an uneventful postoperative recovery. Splenic hypoplasia is an unique entity, which may be seen in the setting of atrial fibrillation and abdominal malignancy.
Splenic hypoplasia may be detected incidentally during radiologic workup or abdominal exploration. Abdominal symptoms or immunologic deficiency are not always present.
PMCID: PMC4561443  PMID: 26417560
Diagnosis; hypoplasia; implications; pathogenesis; splenic aplasia
2.  Gastroesophageal Reflux Symptoms After Laparoscopic Sleeve Gastrectomy for Morbid Obesity. The Importance of Preoperative Evaluation and Selection 
Gastroesophageal reflux disease (GERD) is prevalent in morbidly obese patients, and its severity appears to correlate with body mass index (BMI).
The aim of this study is to investigate the status of GERD after laparoscopic sleeve gastrectomy (LSG).
Materials and Methods:
A prospectively maintained database of all the patients who underwent LSG from February 2008 to May 2011 was reviewed.
A total of 131 patients were included. The mean age and the BMI of the patients were 49.4 years and 48.9 kg/m2, respectively. Prior to LSG, subjective reflux symptoms were reported in 67 (51%) patients. Anatomical presence of hiatal hernia was endoscopically confirmed in 35 (52%) patients who reported reflux symptoms prior to LSG. All these patients underwent simultaneous hiatal hernia repair during their LSG. The overall mean operative time was 106 min (range: 48-212 min). There were no intra- and 30-day postoperative complications. Out of the 67 preoperative reflux patients, 32 (47.7%) reported resolution of their symptoms after the operation, 20 (29.9%) reported clinical improvement, and 12 (22.2%) reported unchanged or persistent symptoms. Three patients developed new-onset reflux symptoms, which were easily controlled with proton pump inhibitors. No patient required conversion to gastric bypass or duodenal switch because of the severe reflux symptoms. At 18 months, the follow-up data were available in 60% of the total patients.
LSG results in resolution or improvement of the reflux symptoms in a large number of patients. Proper patient selection, complete preoperative evaluation to identify the presence of hiatal hernia, and good surgical techniques are the keys to achieve optimal outcomes.
PMCID: PMC4462813  PMID: 26110129
Gastroesophageal reflux symptoms; hiatal hernia; laparoscopic sleeve gastrectomy (LSG)
3.  Comparison of Vertical Sleeve Gastrectomy Versus Biliopancreatic Diversion 
Vertical sleeve gastrectomy (VSG) was originally performed as the first-stage of biliopancreatic diversion with duodenal switch (BPD/DS) for superobesity as a strategy to reduce perioperative complications and morbidity. VSG is now considered a definitive procedure because of its technical simplicity and promising outcomes.
To analyze the outcomes of laparoscopic VSG and to compare them with those of single-stage laparoscopic BPD/DS.
Materials and Methods:
A retrospective review of 200 consecutive patients who underwent VSG and BPD/DS between 2008 and 2011.
A total of 100 patients underwent laparoscopic VSG and 100 patients underwent laparoscopic BPD/DS. The patients in VSG group were older, but gender distribution and body mass index were comparable. Mean operative time for VSG was significantly shorter compared with that of BPD/DS. A single patient in each groups required open conversion. Staple line leak (n = 1) and intraluminal hemorrhage into the newly-created sleeve (n = 1) occurred in the BPD/DS group. Mean length of stay was shorter after VSG (3.1 vs. 3.9 days). At 6 months postoperatively, excess weight loss between the two groups revealed statistically significant difference, favoring BPD/DS.
Despite promising outcomes and technical simplicity of VSG, BPD/DS provides significantly superior excess weight loss in morbidly obese patients.
PMCID: PMC3938871  PMID: 24678475
Biliopancreatic diversion; biliopancreatic diversion; comparison; sleeve gastrectomy
4.  Outcome Analysis of Early Laparoscopic Sleeve Gastrectomy Experience 
This report suggests that laparoscopic sleeve gastrectomy is safe and effective as a definitive bariatric procedure.
Background and Objectives:
Laparoscopic vertical sleeve gastrectomy (LSG) was initially performed as the first stage of biliopancreatic diversion with duodenal switch in the superobese population. In the past few years, however, LSG has been performed as a definitive procedure because of its promising early and midterm results. In this study we describe our initial experience and outcomes with LSG as a potential independent bariatric operation.
A prospectively maintained database including all patients between 2008 and 2011 was reviewed.
A total of 100 initial consecutive patients (69 women and 31 men) were included, with a mean age of 50 years (range, 19–79 years) and body mass index of 49 kg/m2 (range, 36.6–70.3 kg/m2). The mean operative time was 106 minutes (range, 58–212 minutes) with a 2% conversion rate. Thirty-day perioperative complications included port-site hemorrhage (1.0%) and the inability to tolerate oral intake resulting in dehydration (3%). The reoperation rate was 2%, and the mean length of stay was 3.1 days (range, 2–12 days). In one patient with a prolonged hospital stay, an acute cholecystitis developed, and prosthetic heart valve complications developed in another patient. The mean excess body weight loss was 18%, 31.7%, 45%, 52%, 58.4%, and 64% at 1, 3, 6, 9, 12, and 18 months postoperatively, respectively. No deaths occurred in this series.
Satisfactory outcomes and low complication rates were observed after LSG. Our findings suggest that LSG is safe and effective to serve as a definitive bariatric procedure.
PMCID: PMC3866065  PMID: 24398203
Laparoscopic sleeve gastrectomy; Outcomes; Complications
5.  Impact of Minimally Invasive/Bariatric Surgery Fellowship on Perioperative Complications and Outcomes in the First Year of Practice 
Several reports have described worse perioperative outcomes of laparoscopic gastric bypass procedure during learning curve, which improved after completion of one-year fellowship training.
The aim of this study was to evaluate the immediate impact of fellowship training on perioperative complications and outcomes of various bariatric procedures.
Materials and Methods:
One hundred initial patients who underwent laparoscopic gastric banding, laparoscopic Roux-en-Y gastric bypass, laparoscopic vertical sleeve gastrectomy, and robotically-assisted laparoscopic biliopancreatic diversion with duodenal switch by a single fellowship trained surgeon were analyzed.
Overall average Body Mass Index (BMI) of the patients was 45.9 kg/m2, age was 47.5 years, and the American Society of Anesthesiologist Score was 2.89. There were no intraoperative, major 30-day complications, or open conversions. Average operative time was 62 minutes in gastric banding, 160 minutes in gastric bypass, 119 minutes in vertical sleeve gastrectomy, and 320 minutes in biliopancreatic diversion. Length of stay ranged from 0.5 day after gastric banding to 3.9 days after biliopancreatic diversion. The perioperative complications and outcomes are comparable with those reported by experienced surgeons. No mortality occurred in this series.
Bariatric fellowship ensured skills acquisition for new surgeons to safely and effectively perform various types of bariatric operations, with minimal perioperative complications and excellent outcomes.
PMCID: PMC3759069  PMID: 24020051
Complications; Fellowship; Impact; Outcomes
7.  A novel use of endoscopic cutter: Endoscopic retrieval of a retained nasogastric tube following a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch 
A nasogastric tube is utilized routinely by many bariatric surgeons to assist creation of gastrojejunal anastomosis during roux-en-y gastric bypass or duodenojejunal anastomosis during biliopancreatic diversion. However, inadvertent stapling or suturing of the nasogastric tube has been known as a potential complication of this technique.
Case Report:
We describe a successful endoscopic removal of an inadvertently sutured nasogastric tube at the level of the duodenojejunal anastomosis in a 30-year-old woman undergoing a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch for super morbid obesity.
Endoscopic technique is a feasible and safe minimally invasive technique to release a retained nasogastric tube with preservation of the newly created anastomosis. This option gives major advantages of avoiding a re-operation, as well as the potential general anesthetic complications.
PMCID: PMC3271431  PMID: 22363090
Endoscopic retrieveal; Endoscopic cutter; Retained nasogastric tube
8.  Endovascular management of the patent inferior mesenteric artery in two cases of uncontrolled type II endoleak after endovascular aneurysm repair 
Endovascular aneurysm repair (EVAR) has well documented advantages over traditional open repair and has been widely adopted as the alternative treatment modality for abdominal aortic aneurysm. However, endoleaks specifically type II can be a significant problem with this technique leading to aortic sac expansion and potential rupture. A large number of type II endoleaks are caused by persistent inferior mesenteric artery (IMA) retrograde bleeding. Various methods to try to manage this complication have been previously described. IMA embolization via the marginal artery of Drummond, however, has not been adequately popularized as an alternative less invasive approach to the treatment of type II endoleak.
Case Report:
Two men, ages 77 and 81, underwent uneventful EVAR for 5.5 and 5.0 cm infrarenal abdominal aortic aneurysms, respectively, using Zenith Cook® bifurcated stent grafts. Computed tomography angiography at 1 and 6 months postoperatively demonstrated small type II endoleaks in both cases which were followed clinically. Subsequent follow-up tomography scan at 12 months revealed persistent type II endoleaks related to retrograde filling from the IMA with significant enlargement of the aneurysm sacs. Both patients underwent successful IMA coil embolization via the marginal artery of Drummond.
Percutaneous IMA embolization using standard endovascular techniques to access the marginal artery of Drummond is an alternative, and in our opinion, preferred technique for controlling type II endoleaks caused by a persistently patent IMA.
PMCID: PMC3234148  PMID: 22171248
Endoleak; marginal artery; drummond; coil embolization
9.  Ganglioneuroma of the adrenal gland and retroperitoneum: A case report 
Ganglioneuromas are benign tumors of the sympathetic nervous system that rarely arise in the adrenal gland. Majority of cases are detected incidentally since they are usually asymptomatic. Up to the current era of laparoscopic adrenal mass excision, this unusual entity has not been adequately reported in the surgical literature.
Case Report:
A 51 year old male with history of hypertension was found to have abdominal bruit during a regular physical examination. A 4 cm right adrenal mass with upper pole calcification and a 6 cm retro-pancreatic mass were subsequently found on a computed tomography scan. Endoscopic ultrasound-guided needle biopsy was indeterminate. Preoperative endocrine evaluation showed mildly elevated vanillyl mandelic acid with normal 24-hour cathecolamine, metanephrine and cortisol levels. Histopathologic examination after an uneventful laparoscopic excision was consistent with ganglioneuroma.
Ganglioneuroma occurs rarely in adrenal gland and preoperative diagnosis is difficult since symptoms are usually nonspecific. Due to widespread utilization of abdominal imaging, however, it should be included in differential diagnosis of adrenal or retroperitoneal mass. Histopathologic examination is currently the mainstay of diagnosis.
PMCID: PMC3336884  PMID: 22540109
Ganglioneuroma; retroperitoneum; adrenal gland; excision
10.  Spontaneous massive hemoperitoneum: A potentially life threatening presentation of the wandering spleen 
Wandering spleen is an unusual condition characterized by the absence or maldevelopment of one or all of the ligaments securing the spleen in its normal position in the left upper abdomen. Pedicular tortion with a complete vascular disruption is a rare but known potential complication of this mostly congenital disorder. Spontaneous hemoperitoneum with acute abdomen however, is a life threatening situation that has not been adequately reported in the adult literature.
Case Report:
A forty four year old man presented to the emergency department with an acutely distended and rigid abdomen. His past medical history was only significant for mild mental retardation. The patient denies prior abdominal operation or recent trauma. On initial examination, he appeared to be anxious, pale, and tachycardic. Fullness in the midpelvic region was easily appreciated on palpation. An enlarged pelvic spleen and free intraperitoneal fluid consistent with blood were seen on a CT scan. The patient was promptly taken for an exploratory laparotomy where a large rush of blood was encountered upon entering the abdomen. A volvulus of the splenic pedicle with an infarcted spleen was found mandating a splenectomy.
Abnormally located spleen, splenomegaly, and finding of hemoperitoneum are highly suggestive of wandering spleen with tortioned pedicle. Despite its life threatening presentation, immediate laparotomy and splenectomy invariably result in good outcome.
PMCID: PMC3336896  PMID: 22540075
Wandering spleen; pedicular tortion; hemoperitoneum; splenectomy
11.  Surgical management of endoscopically unresectable duodenal gangliocytic paraganglioma in a patient with partial upper gastrointestinal obstruction 
Gangliocytic paragangliomas are unusual and often misunderstood tumors that occur almost exclusively in the second portion of the duodenum, although they have been described in other sites such as the urinary bladder, spermatic cord, prostate, urethra, uterus and scalp. We describe our experience with the surgical management of an endoscopically unresectable gangliocytic paraganglioma located in the third part of the duodenum causing a partial upper gastrointestinal obstruction.
Case Report:
A fifty-two-year-old male presented to the Geisinger clinic with a four-year history of postprandial projectile vomiting associated with epigastric discomfort. Computed tomography scan revealed an oval-shaped filling defect in the third part of the duodenum. Endoscopic ultrasonography showed a 22 × 16 × 35 mm submucosal mass that was not amenable to an endoscopic resection. Exploratory laparotomy revealed an absence of extraduodenal involvement. A long-stalked tumor was successfully excised and extruded through a longitudinal duodenotomy. The pathology report showed a gangliocytic paraganglioma with negative lymph nodes.
In patients presenting with prolonged recurrent attacks of vomiting, diagnostic workup to exclude anatomic causes is mandatory. Gangliocytic paraganglioma must be considered in the differential diagnosis of an intraduodenal tumor.
PMCID: PMC3338220  PMID: 22558565
Paraganglioma; duodenum; surgical management
12.  Gallbladder neurofibroma presenting as chronic epigastric pain - Case report and review of the literature 
Benign nonepithelial neoplasms of the gallbladder are unusual. The majority of gallbladder neurofibromas are found incidentally in the gallbladder specimens following cholecystectomy. There have been only few reports in the literature describing this rare entity. In this study we report a case of gallbladder neurofibroma presenting as chronic epigastric pain in a young patient.
Case Report:
A thirty two year old otherwise healthy man presented to our clinic with chronic epigastric pain symptom after eating. Physical examination, laboratory and radiologic workups were unremarkable for signs of biliary tract diseases. Past medical and surgical histories were significant only for neurofibromatosis type I. Due to persistent symptomatology, the patient was taken to the operating room for a diagnostic laparoscopy followed by laparoscopic cholecystectomy. Open conversion was necessitated because of the presence of a gallbladder mass preventing safe anatomic dissection. Surgical pathology revealed plexiform neurofibroma with noninflamed gallbladder. The postoperative course was unremarkable and the patient was pain free at 3 weeks postoperatively.
Benign neoplasms such as gallbladder neurofibroma should be included in the differential diagnosis for chronic epigastric pain symptom in a young otherwise healthy patient with neurofibromatosis. Diagnostic laparoscopy should be considered in an individual presenting with this condition.
PMCID: PMC3339114  PMID: 22558554
Neurofibroma; gallbladder; benign tumors
13.  Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction - An alternative surgical technique for central pancreatic mass resection 
Central pancreatectomy has gained popularity in the past decade as treatment of choice for low malignant potential tumor in the midpancreas due to its ability to achieve optimal preservation of pancreatic parenchyma. Simultaneously, advancement in minimally invasive approach has contributed to numerous novel surgical techniques with significantly lower morbidity and mortality. With the purpose of improving patient outcomes, we describe a laparoscopic assisted central pancreatectomy with pancreaticogastrostomy as an alternative method to the previously described open central pancreatectomy with roux-en-y pancreaticojejunostomy reconstruction.
Case Report:
A 39 year old man presented to our clinic with a 2.5 cm neuroendocrine tumor at the neck of the pancreas. Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction was successfully performed. Operative time was 210 minutes with blood loss of 200 ml. Postoperative course was uneventful except for a minimal pancreatic leak which was controlled by an intraoperatively placed closed suction drain. At 2 week follow up, patient was asymptomatic with well preserved pancreatic endo and exocrine functions. Permanent pathology findings showed a well differentiated neuroendocrine tumor with negative margins and nodes.
Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction is feasible and safe for a centrally located tumor. Laparoscopic assisted technique facilitates application of minimally invasive approach by increasing surgical feasibility in typically complex pancreatic operations.
PMCID: PMC3339104  PMID: 22558594
Laparoscopic; central pancreatectomy; pancreaticogastrostomy
14.  Postoperative mesenteric venous thrombosis: Potential complication related to minimal access surgery in a patient with undiagnosed hypercoagulability 
Mesenteric venous thrombosis is a rare but potentially fatal complication associated with laparoscopy which has now become common practice and gold standard for many procedures in general surgery. There are only few scattered case reports in the literature describing this postoperative thrombotic event.
Case Report:
In the present study, we describe a patient presenting with severe abdominal pain at 25 days following an uneventful laparoscopic paraesophageal hernia (PEH) repair and nissen fundoplication. Exploratory laparotomy revealed an extensive small bowel ischemia requiring bowel resection followed by a second look laparotomy. Retrospectively performed hematologic workup revealed a genetic mutation associated with hyperhomocysteinemia in addition to her hyperfibrinogenemia. Previously published data were collected and discussed.
Mesenteric venous thrombosis is a rare but potentially serious complication after laparoscopic surgery especially in patients with underlying hypercoagulability. High index of suspicion is important in early diagnosis and subsequent treatment.
PMCID: PMC3341641  PMID: 22558583
Mesenteric venous thrombosis; laparoscopy; hypercoagulability

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