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Ganam S, Englander K, Paturu T, Sujka J, Velanovich V. Does fixation of the Enterra device to the abdominal fascia cause device flipping inside the pocket? J Gastrointest Surg 2024:S1091-255X(24)00415-3. [PMID: 38641162 DOI: 10.1016/j.gassur.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/05/2024] [Accepted: 04/13/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Samer Ganam
- Morsani College of Medicine, University of South Florida, Tampa, Florida; Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, Florida.
| | | | - Tejasvi Paturu
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Joseph Sujka
- Morsani College of Medicine, University of South Florida, Tampa, Florida; Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, Florida
| | - Vic Velanovich
- Morsani College of Medicine, University of South Florida, Tampa, Florida; Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, Florida
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Sher T, Noom M, Ganam S, Sujka J, Rinde-Hoffman D, DuCoin C. Temporary Mechanical Circulatory Support During Bariatric Surgery: A Novel Bridge to Durable Left Ventricular Assist Device and Cardiac Transplantation. Am Surg 2024:31348241244637. [PMID: 38578069 DOI: 10.1177/00031348241244637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Advanced heart failure (HF) with comorbid severe obesity presents a unique surgical dilemma: bariatric surgery may help patients meet cardiac transplantation body mass index (BMI) criteria, but poor cardiac function puts them at increased intraoperative risk. Per International Society for Heart and Lung Transplantation (ISHLT) guidelines BMI > 35 is a contraindication for orthotopic heart transplantation. Temporary mechanical circulatory support (MCS) with Impella 5.5 during bariatric surgery, as presented in this report, may help solve this dilemma for some patients. We present three patients with severe obesity and advanced heart failure (HF) who underwent successful bariatric surgery while supported by Impella 5.5 (Abiomed, Inc., Danvers, MA).
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Affiliation(s)
- Theo Sher
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Madison Noom
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Samer Ganam
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Joseph Sujka
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Debbie Rinde-Hoffman
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Heart Failure Center of Excellence, Heart and Vascular Institute, Tampa General Medical Group/University of South Florida, Tampa, FL, USA
| | - Christopher DuCoin
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Englander K, Ganam S, Paturu T, Sujka J, Velanovich V. Reoperation after gastric neurostimulation device placement: A descriptive study. J Gastrointest Surg 2024:S1091-255X(24)00393-7. [PMID: 38574962 DOI: 10.1016/j.gassur.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/19/2024] [Accepted: 03/30/2024] [Indexed: 04/06/2024]
Affiliation(s)
- Katherine Englander
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Samer Ganam
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Tejasvi Paturu
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Joseph Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Vic Velanovich
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, United States.
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Englander K, Cox K, Smith T, Diab A, Ganam S, Sujka J, DuCoin C. The Financial Implications of a Single-Use Device Reprocessing Program at a Tertiary Referral Center Surgical Department. Am Surg 2024:31348241241679. [PMID: 38561960 DOI: 10.1177/00031348241241679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The operating room has been identified as one of the primary contributors to waste and energy expenditure in the health care system. The primary objective of our study was to evaluate the efficacy of single-use device reprocessing and report the cost savings, waste diversion, and reduction in carbon emissions. Data was collected from January 2021 to April 2023. Medline collected the data for analysis and converted it from an Excel file format to SPSS (Version 27) for analysis. Descriptive frequencies were used for data analysis. We found a mean monthly cost savings of $16,051.68 and a mean 700.68 pounds of waste a month diverted, resulting in an estimated yearly saving of $2354.29 in disposal costs and a reduction of 1112.65 CO2e emissions per month. This program has made significant contributions to cost savings and environmental efforts.
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Affiliation(s)
| | - Kaitlyn Cox
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Teagen Smith
- Department of Biostatistics, University of South Florida, Tampa, FL, USA
| | - Adbul Diab
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Samer Ganam
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Joseph Sujka
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Christopher DuCoin
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Ahmed A, Gandhi S, Ganam S, Diab ARF, Mhaskar R, Sujka J, DuCoin C, Docimo S. Ventral hernia repair using bioresorbable poly-4-hydroxybutyrate mesh in clean and contaminated surgical fields: a systematic review and meta-analysis. Hernia 2024; 28:575-584. [PMID: 38345668 DOI: 10.1007/s10029-023-02951-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/16/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Use of biologic or synthetic mesh in hernia repair shifts is based on evolving evidence. Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh is a potential alternative to biologic and synthetic mesh in ventral hernia repair (VHR). This meta-analysis assesses the efficacy of P4HB mesh in clean and contaminated surgical settings. METHODS Two authors searched literature on PubMed, reviewing titles and abstracts of all articles to determine inclusion eligibility. Post-operative data were compared via transformation method to convert the proportion of patients with the outcome of interest into a suitable quantity for random-effects synthesis using STATA software. RESULTS Initial search yielded 287 citations. Six studies were included and categorized on whether hernia repairs were conducted in clean (CDC class I) or contaminated cases (CDC class II-IV). The pooled proportion of surgical site infection (SSI), surgical site occurrence (SSO), hernia recurrence, total surgical complications, and reoperation were calculated in 391 clean and 81 contaminated cases. For clean vs. contaminated cases, the following pooled proportions were noted: SSI (2% (CI 0-7%) vs 9% (CI 0-025) (p = 0.03), SSO: 14% (CI 5-25%) vs 35% (CI 22-50%) (p = 0.006), hernia recurrence (8% (CI 1-19%) vs 4% (CI 0-12%) (p = 0.769); surgical complications (17% (CI 6-32%) vs 50% (CI 27-72%) (p = 0.009). Reoperation data were available in 298 clean cases across four studies: 5% (CI 0-15%). CONCLUSIONS P4HB biosynthetic mesh may be more effective than previously thought, particularly in clean wounds. P4HB may also be superior to biologic mesh when compared to clinical trial data. Further research is necessary for more direct comparison.
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Affiliation(s)
- A Ahmed
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - S Gandhi
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - S Ganam
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - A-R F Diab
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - R Mhaskar
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - J Sujka
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - C DuCoin
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA
| | - S Docimo
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, FL, USA.
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Choi JH, Diab AR, Tsay K, Kuruvilla D, Ganam S, Saad A, Docimo S, Sujka JA, DuCoin CG. The evidence behind robot-assisted abdominopelvic surgery: a meta-analysis of randomized controlled trials. Surg Endosc 2024:10.1007/s00464-024-10773-3. [PMID: 38528261 DOI: 10.1007/s00464-024-10773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/24/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Despite recent advancements, the advantage of robotic surgery over other traditional modalities still harbors academic inquiries. We seek to take a recently published high-profile narrative systematic review regarding robotic surgery and add meta-analytic tools to identify further benefits of robotic surgery. METHODS Data from the published systematic review were extracted and meta-analysis were performed. A fixed-effect model was used when heterogeneity was not significant (Chi2 p ≥ 0.05, I2 ≤ 50%) and a random-effects model was used when heterogeneity was significant (Chi2 p < 0.05, I2 > 50%). Forest plots were generated using RevMan 5.3 software. RESULTS Robotic surgery had comparable overall complications compared to laparoscopic surgery (p = 0.85), which was significantly lower compared to open surgery (odds ratio 0.68, p = 0.005). Compared to laparoscopic surgery, robotic surgery had fewer open conversions (risk difference - 0.0144, p = 0.03), shorter length of stay (mean difference - 0.23 days, p = 0.01), but longer operative time (mean difference 27.98 min, p < 0.00001). Compared to open surgery, robotic surgery had less estimated blood loss (mean difference - 286.8 mL, p = 0.0003) and shorter length of stay (mean difference - 1.69 days, p = 0.001) with longer operative time (mean difference 44.05 min, p = 0.03). For experienced robotic surgeons, there were less overall intraoperative complications (risk difference - 0.02, p = 0.02) and open conversions (risk difference - 0.03, p = 0.04), with equivalent operative duration (mean difference 23.32 min, p = 0.1) compared to more traditional modalities. CONCLUSION Our study suggests that compared to laparoscopy, robotic surgery may improve hospital length of stay and open conversion rates, with added benefits in experienced robotic surgeons showing lower overall intraoperative complications and comparable operative times.
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Affiliation(s)
- Jae Hwan Choi
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Abdul-Rahman Diab
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Katherine Tsay
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Davis Kuruvilla
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Samer Ganam
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Adham Saad
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Salvatore Docimo
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
| | - Joseph A Sujka
- Department of Surgery, University of South Florida, Tampa, FL, 33620, USA
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Awshah S, Mhaskar R, Diab ARF, Read M, Coughlin E, Ganam S, Saad AR, Sujka J, DuCoin C. Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy. J Am Coll Surg 2024:00019464-990000000-00946. [PMID: 38497555 DOI: 10.1097/xcs.0000000000001074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed. STUDY DESIGN PubMed, Embase and Scopus databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane ROBINS-I tool. Assessed outcomes included intra- and post-operative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random effects model to report odds ratio (OR) and 95% confidence intervals (95% CIs) and continuous data to report mean difference (MD) and 95% CIs. RESULTS Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic, 168,335 laparoscopic patients) studies assessed HHR outcomes, while nine (2,384 robotic, 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a non-significantly shorter length of hospital stay (LOS) [MD -0.41 (95% CI -0.87, -0.05)], fewer conversions to open [OR 0.22 (95% CI 0.03, 1.49)], and lower morbidity rates [OR 0.76 (95% CI 0.47, 1.23)]. Robotic HM led to significantly fewer esophageal perforations [OR 0.36 (95% CI 0.15, 0.83)], reinterventions [OR 0.18 (95% CI 0.07, 0.47)] a non-significantly shorter LOS [MD -0.31 (95% CI -0.62, 0.00)]. Both robotic HM and HHR had significantly longer operative times. CONCLUSIONS Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the two methods, given the low to moderate quality of included studies.
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Affiliation(s)
- Sabrina Awshah
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Rahul Mhaskar
- University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Medical Education, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Abdul-Rahman Fadi Diab
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Meagan Read
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Emily Coughlin
- University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Medical Education, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Samer Ganam
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Adham R Saad
- University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Joseph Sujka
- University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Christopher DuCoin
- University of South Florida Morsani College of Medicine, Tampa, FL
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
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Ganam S, Tang R, Sher T, Worthey A, Docimo S. Quality of Life in Patients Undergoing Revisional Bariatric Surgery: From Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Obes Surg 2024; 34:997-1003. [PMID: 38308103 DOI: 10.1007/s11695-024-07082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide. However, this surgery may be associated with long-term weight regain and severe gastroesophageal reflux disease (GERD), sometimes necessitating conversion to Roux-en-Y gastric bypass (RYGB) to improve quality of life (QoL). We conducted a systematic review on QoL measures following the conversion of SG to RYGB. We searched various databases for studies conducted between January 2005 and September 2023. Four studies, involving 196 participants in total, met the inclusion criteria. Different assessment methods were used to evaluate QoL following the conversion. In the included studies, we observed that GERD symptoms and proton pump inhibitor (PPI) use both decreased following conversion to RYGB. Excess weight loss (EWL) was also observed in all studies.
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Affiliation(s)
- Samer Ganam
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA.
- Division of Gastrointestinal Surgery, Tampa General Hospital, Horatio Street, Tampa, FL, 33609, USA.
| | - Ryan Tang
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA
| | - Theo Sher
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA
| | - Ayana Worthey
- Division of Gastrointestinal Surgery, Tampa General Hospital, Horatio Street, Tampa, FL, 33609, USA
| | - Salvatore Docimo
- Morsani College of Medicine, University of South Florida, Horatio Street, Tampa, FL, 33609, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Horatio Street, Tampa, FL, 33609, USA
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Ganam S, Malcolm Taylor G, DuCoin C. Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia. J Vis Exp 2024. [PMID: 38436417 DOI: 10.3791/66224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the failure of the LES to relax. Patients typically complain of dysphagia, chest pain, and regurgitation. They often report drinking liquids with solids intake to help propel food boluses into the stomach. The diagnosis of achalasia is typically confirmed with an esophagogram and a motility study (esophageal manometry). An esophagogram classically shows the bird beak sign with tapering in the distal esophagus. The treatment for achalasia includes both surgical and non-surgical options. Surgical treatment is associated with a lower rate of recurrences, high clinical success rate, and durability of symptom relief. The current gold standard of surgical technique is myotomy, or the dividing of the muscle fibers of the distal esophagus. Surgical myotomy can be accomplished via a laparoscopic or robotic technique; per-oral endoscopic myotomy is a new alternative intervention. Due to the theoretical risk of gastroesophageal reflux following a myotomy, an antireflux procedure is sometimes performed. We reviewed the approach to a robotic heller myotomy for the treatment of achalasia.
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Affiliation(s)
- Samer Ganam
- Morsani College of Medicine, University of South Florida; Division of Gastrointestinal Surgery, Tampa General Hospital;
| | - George Malcolm Taylor
- Morsani College of Medicine, University of South Florida; Division of Gastrointestinal Surgery, Tampa General Hospital
| | - Christopher DuCoin
- Morsani College of Medicine, University of South Florida; Division of Gastrointestinal Surgery, Tampa General Hospital
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Bickel A, Lagrissi R, Jerushalmi J, Sbeit W, Weiss M, Shiller M, Ganam S, Kakiashvili E. The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy. Dig Surg 2023; 40:178-186. [PMID: 37748452 DOI: 10.1159/000533794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. METHODS We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. RESULTS Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. CONCLUSIONS Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.
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Affiliation(s)
- Amitai Bickel
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Ron Lagrissi
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Jacqueline Jerushalmi
- Nuclear Medicine Institute, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Michael Weiss
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Moshe Shiller
- Department of Gastroenterology, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Samer Ganam
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Eli Kakiashvili
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
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Bickel A, Akinichev K, Weiss M, Ganam S, Biswas S, Waksman I, Kakiashvilli E. Challenges in abdominal re-exploration for war casualties following on-site abdominal trauma surgery and subsequent delayed arrival to definitive medical care abroad - an unusual scenario. BMC Emerg Med 2022; 22:132. [PMID: 35850737 PMCID: PMC9295351 DOI: 10.1186/s12873-022-00687-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background During the Syrian civil war, patients were initially treated on-site in Syria and later transferred to medical centers in Israel. Relevant details concerning the exact nature of injury and medical/surgical care received in Syria were unavailable to clinicians in Israel. Many of these patients required abdominal re-exploration for obvious or suspected problems related to their injury. Our aim is to present our approach to abdominal trauma patients who survived initial on-site surgery and needed subsequent abdominal re-exploration abroad, in our medical center. Methods Clinical data from all medical records were retrospectively analyzed. Each patient underwent total body computerized tomography on arrival, revealing diverse multi-organ trauma. We divided the patient population who had abdominal trauma into 4 sub-groups according to the location in which abdominal surgical intervention was performed (abdominal surgery performed only in Syria, surgery in Syria and subsequent re-laparotomy in Israel, abdominal surgery only in Israel, and management of patients without abdominal surgical intervention). We focused on missed injuries and post-operative complications in the re-laparotomy sub-group. Results By July 2018, 1331 trauma patients had been admitted to our hospital, of whom 236 had suffered abdominal trauma. Life-saving abdominal intervention was performed in 138 patients in Syria before arrival to our medical center. A total of 79 patients underwent abdominal surgery in Israel, of whom 46 (33%) required re-laparotomy. The absence of any communication between the surgical teams across the border markedly affected our medical approach. Indications for re-exploration included severe peritoneal inflammation, neglected or overlooked abdominal foreign bodies, hemodynamic instability and intestinal fistula. Mortality occurred in 37/236 patients, with severe abdominal trauma as the main cause of fatality in 10 of them (4.2%), usually following urgent re-laparotomy. Conclusions Lack of information about the circumstances of injury in an environment of catastrophe in Syria at the time and the absence of professional communication between the surgical teams across the border markedly dictated our medical approach. Our concerns were that some patients looked deceptively stable while others had potentially hidden injuries. We had no information on who had had definitive versus damage control surgery in Syria. The fact that re-operation was not performed by the same team responsible for initial abdominal intervention also posed major diagnostic challenges and warranted increased clinical suspicion and a change in our standard medical approach.
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Affiliation(s)
- Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel. .,The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.
| | | | - Michael Weiss
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Seema Biswas
- Department of Surgery B, Galilee Medical Center, Nahariya, Israel
| | - Igor Waksman
- The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.,Department of Surgery B, Galilee Medical Center, Nahariya, Israel
| | - Eli Kakiashvilli
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel
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Bickel A, Ganam S, Abu Shakra I, Farkash I, Francis R, Karra N, Merei F, Cohen I, Kakiashvili E. Delayed diagnosis and subsequently increased severity of acute appendicitis (compatible with clinical-pathologic grounds) during the COVID-19 pandemic: an observational case-control study. BMC Gastroenterol 2022; 22:19. [PMID: 35016616 PMCID: PMC8751470 DOI: 10.1186/s12876-021-02024-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/09/2021] [Indexed: 12/13/2022] Open
Abstract
Background During a global crisis like the current COVID-19 pandemic, delayed admission to hospital in cases of emergent medical illness may lead to serious adverse consequences. We aimed to determine whether such delayed admission affected the severity of an inflammatory process regarding acute appendicitis, and its convalescence. Methods In a retrospective observational cohort case-control study, we analyzed the medical data of 60 patients who were emergently and consecutively admitted to our hospital due to acute appendicitis as established by clinical presentation and imaging modalities, during the period of the COVID-19 pandemic (our study group). We matched a statistically control group consisting of 97 patients who were admitted during a previous 12-month period for the same etiology. All underwent laparoscopic appendectomy. The main study parameters included intraoperative findings (validated by histopathology), duration of abdominal pain prior to admission, hospital stay and postoperative convalescence (reflecting the consequences of delay in diagnosis and surgery). Results The mean duration of abdominal pain until surgery was significantly longer in the study group. The rate of advanced appendicitis (suppurative and gangrenous appendicitis as well as peri-appendicular abscess) was greater in the study than in the control group (38.3 vs. 21.6%, 23.3 vs. 16.5%, and 5 vs. 1% respectively), as well as mean hospital stay. Conclusions A global crisis like the current viral pandemic may significantly affect emergent admissions to hospital (as in case of acute appendicitis), leading to delayed surgical interventions and its consequences.
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13
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Abu Shakra I, Bez M, Ganam S, Francis R, Muati A, Bickel A, Merei F, Talmi Z, Kamal K, Kakiashvili E. The volume of general surgery emergency cases in a government hospital during the COVID-19 pandemic and two other periods: a comparative, retrospective study. BMC Surg 2021; 21:119. [PMID: 33685436 PMCID: PMC7938269 DOI: 10.1186/s12893-021-01131-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background During March and April 2020, reductions in non-COVID-19 hospital admissions were observed around the world. Elective surgeries, visits with general practitioners, and diagnoses of medical emergencies were consequently delayed. Objective
To compare the characteristics of patients admitted to a northern Israeli hospital with common surgical complaints during three periods: the lockdown due to the COVID-19 outbreak, the Second Lebanon War in 2006, and a regular period. Methods Demographic, medical, laboratory, imaging, intraoperative, and pathological data were collected from electronic medical files of patients who received emergency treatment at the surgery department of a single hospital in northern Israel. We retrospectively compared the characteristics of patients who were admitted with various conditions during three periods. Results
Patients’ mean age and most of the clinical parameters assessed were similar between the periods. However, pain was reportedly higher during the COVID-19 than the control period (8.7 vs. 6.4 on a 10-point visual analog scale, P < 0.0001). During the COVID-19 outbreak, the Second Lebanon War, and the regular period, the mean numbers of patients admitted daily were 1.4, 4.4, and 3.0, respectively. The respective mean times from the onset of symptoms until admission were 3, 1, and 1.5 days, P < 0.001. The respective proportions of surgical interventions for appendiceal disease were 95%, 96%, and 69%; P = 0.03. Conclusions Compared to a routine period, patients during the COVID-19 outbreak waited longer before turning to hospitalization, and reported more pain at arrival. Patients during both emergency periods were more often treated surgically than non-operatively.
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Affiliation(s)
- Ibrahim Abu Shakra
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Maxim Bez
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel.,Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Rola Francis
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Amir Muati
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Ziv Talmi
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Khatib Kamal
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel. .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
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14
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Abu Shakra I, Bez M, Bickel A, Badran M, Merei F, Ganam S, Kassis W, Kakiashvili E. Emergency open surgery with a duodenotomy and successful removal of an impacted basket following a complicated endoscopic retrograde cholangiopancreatography procedure: a case report. J Med Case Rep 2021; 15:93. [PMID: 33618756 PMCID: PMC7901177 DOI: 10.1186/s13256-020-02608-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/30/2020] [Indexed: 12/14/2022] Open
Abstract
Background Current management of choledocholithiasis entails the use of endoscopic retrograde cholangiopancreatography (ERCP) and clearance of the common bile duct. A rare complication of this procedure is the impaction of the basket by a large stone, which necessitates lithotripsy. Here we report a case of an impacted basket during ERCP, which was managed by open surgery with a duodenotomy and the manual removal of the basket. Case presentation A 79-year-old Caucasian man was admitted to our department with yellowish discoloration of urine, skin and eyes. Abdominal ultrasonography showed a slightly thickened gallbladder, multiple gallbladder stones, dilated intrahepatic bile ducts and extrahepatic bile extending to 1.1 cm. A computed tomography (CT) scan demonstrated a stone in the common bile duct, which caused dilation of the biliary ducts. The patient was diagnosed with obstructive jaundice secondary to choledocholithiasis; and underwent an ERCP, a sphincterotomy and stone extraction. Four days following discharge, the patient was readmitted with jaundice, abdominal pain, vomiting and fever. He was diagnosed with ascending cholangitis and treated initially with antibiotics. A second ERCP revealed a dilated common bile duct and choledocholithiasis. Stone removal with a basket failed, as did mechanical lithotripsy. Finally, the wires of the basket were ruptured and stacked in the common bile duct together with the stone. During exploratory laparotomy, adhesiolysis, a Kocher maneuver of the duodenum and a subtotal cholecystectomy were performed. Choledochotomy did not succeed in removing the impacted wires together with the stone. Therefore, a duodenotomy and an extension of the sphincterotomy were performed, followed by high-pressure lavage of the common bile duct to remove additional small biliary stones. The choledochotomy and duodenotomy were closed by a one-layer suture, and a prophylactic gastroenterostomy was performed to prevent leakage from the common bile duct and the duodenum. The postoperative course was satisfactory. Conclusions This is the first report in the literature of removal of an impacted Dormia basket through the papilla by performing a duodenotomy and an extension of the sphincterotomy, followed by gastroenterostomy.
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Affiliation(s)
- Ibrahim Abu Shakra
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Mahran Badran
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Walid Kassis
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, 22100, Nahariya, Israel. .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
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15
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Kakiashvili E, Shakra IA, Karra N, Merei F, Bickel A, Ganam S, Khuri S, Bez M. Multiple metastases from colorectal cancer isolated to the spleen: a rare entity. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05109-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Kakiashvili E, Bez M, Abu Shakra I, Ganam S, Bickel A, Merei F, Drobot A, Bogouslavski G, Kassis W, Khatib K, Badran M, Kluger Y, Almog R. Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia? Asian J Surg 2021; 44:93-98. [DOI: 10.1016/j.asjsur.2020.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/09/2020] [Accepted: 03/23/2020] [Indexed: 02/02/2023] Open
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17
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Drobot A, Bez M, Abu Shakra I, Merei F, Khatib K, Bickel A, Ganam S, Bogouslavski G, Karra N, Mahran B, Kassis W, Kogan L, Drobot D, Weiss M, Koshima I, Kakiashvili E. Microsurgery for management of primary and secondary lymphedema. J Vasc Surg Venous Lymphat Disord 2020; 9:226-233.e1. [PMID: 32446874 DOI: 10.1016/j.jvsv.2020.04.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. METHODS A retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. RESULTS LVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. CONCLUSIONS LVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.
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Affiliation(s)
- Assi Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Ibrahim Abu Shakra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Kamal Khatib
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Grigori Bogouslavski
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Nour Karra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Badran Mahran
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Walid Kassis
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Leonid Kogan
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Denis Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Michael Weiss
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel.
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18
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Abu Shakra I, Bez M, Bickel A, Kassis W, Ganam S, Merei F, Karra N, Kamal K, Fischer D, Kakiashvili E. Chylous ascites as a late complication of one anastomosis gastric bypass-minigastric bypass: case report. BMC Surg 2020; 20:91. [PMID: 32375726 PMCID: PMC7204015 DOI: 10.1186/s12893-020-00758-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/28/2020] [Indexed: 11/17/2022] Open
Abstract
Background One anastomosis gastric bypass- minigastric bypass (OAGB-MGB) is an emerging bariatric surgery that is being endorsed by surgeons worldwide. Internal herniation is a rare and dreaded complication after malabsorptive bariatric procedures, which necessitates early diagnosis and intervention. Case presentation We describe a 29-year-old male with chylous ascites caused by an internal hernia 8 months following laparoscopic one anastomosis gastric bypass. An abdominal CT showed enlargement of lymph nodes at the mesentery, with a moderate amount of liquid in the abdomen and pelvis. An emergent exploratory laparoscopic surgery demonstrated an internal hernia at the Petersen’s space with a moderate quantity of chylous ascites. The patient made an uneventful recovery after surgery. Conclusions Internal herniation can occur after OAGB-MGB and in extremely rare cases lead to chylous ascites. To our knowledge, this is the first reported case of chylous ascites following one anastomosis gastric bypass.
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Affiliation(s)
| | - Maxim Bez
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.,Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Walid Kassis
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Nour Karra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Khatib Kamal
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Doron Fischer
- Department of Radiology, Galilee Medical Center, Nahariya, Israel
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel. .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
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19
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Merei F, Shapiro G, Abu Shakra I, Bickel A, Ganam S, Bez M, Kakiashvili E. A unusual case of multifocal pyogenic abscess formation following ERCP procedure. BMC Surg 2020; 20:92. [PMID: 32375832 PMCID: PMC7203808 DOI: 10.1186/s12893-020-00759-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic disorders. Infection is the most morbid complication of ERCP and among the most common causes of ERCP-related death. Case presentation A 69-year-old man presented with right upper quadrant abdominal pain, obstructive jaundice and abnormal liver function tests. Ultrasound revealed cholelithiasis without bile duct dilation. After receiving intravenous antibiotics for acute cholecystitis, the patient was discharged. Two weeks later, an endoscopic ultrasound demonstrated gallstones and CBD dilation of up to 6.4 mm with 2 filling defects. An ERCP was performed with a papillotomy and stone extraction. Twenty-four hours post-ERCP the patient developed a fever, chills, bilirubinemia and elevated liver function tests. Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, the patient remained febrile, with a diffusely tender abdomen and elevated inflammatory markers. A CT revealed a very small hypodense lesion in the seventh liver segment. Extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified, and the antibiotics were switched to Imipenem and Cilastatin. The hypodense lesion in the liver increased to 1.85 cm and a new hypodense lesion was seen in the right psoas. At day 10 post-ERCP, the patient started having low back pain and difficulty walking. MRI revealed L4-L5 discitis with a large epidural abscess, spanning L1-S1 and compressing the spinal cord. Decompressive laminectomy of L5 was done and Klebsiella pneumonia was identified. Due to continued drainage from the wound, high fever, we performed a total body CT which revealed increased liver and iliopsoas abscess. Decompressive laminectomy was expanded to include L2-L4 and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. Multidisciplinary panel discussion was performed, and it was decided to continue with a non invasive approach . Conclusions Early recognition of complications and individualized therapy by a multi-disciplined team is important for managing post-ERCP septic complications. Particular attention should be given to adequate coverage by empiric antibiotics.
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Affiliation(s)
- Fahed Merei
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | | | | | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safad, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel. .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safad, Israel.
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20
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Drobot A, Ganam S, Karra N, Bickel A, Abu Shakra I, Kakiashvili E. Resection of an axillary macrocystic lymphatic malformation in a 14-year-old girl using intraoperative indocyanine green lymphography. J Vasc Surg Venous Lymphat Disord 2020; 9:504-507. [PMID: 32325148 DOI: 10.1016/j.jvsv.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 04/06/2020] [Indexed: 11/26/2022]
Abstract
Lymphangioma is a malformation of the lymphatic system for which surgical excision is a possible treatment. However, complete excision may be hindered by the lesion's size, anatomic location, unclear borders, and invasion into adjacent tissues. We describe a 14-year-old girl who presented with a rapidly progressing axillary swelling. Magnetic resonance imaging and ultrasound revealed a lymphatic macrocystic multilocular lesion. After preoperative and intraoperative indocyanine green lymphography, a complete surgical excision was achieved without damage to collateral lymphatic channels or surrounding tissues. Intraoperative indocyanine green lymphography may be useful in achieving efficient and safe resection of lymphangioma without damaging unconnected lymphatics.
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Affiliation(s)
- Assi Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Nour Karra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | | | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.
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