STUMP THE STARS: CASE PRESENTATIONS FROM THE

COMMONWEALTHBruce Schirmer, M.D.

CASE 1• 36 yo male, BMI 54, weight 460• Disability due to chronic back and joint pain• Comorbid problems: HTN, CHF, OSA, gout, DJD, LB pain, venous stasis ulcers, NAFLD• Previous sigmoid colostomy for trauma with reversal

CASE 1•Only son of very doting parents•Lives at home with them•Takes 80 mg oxycontin tid for back pain plus percocet•Smokes half pack per day•Medicare insurance•Wants gastric bypass

OPERATIVE CHOICEIs this the right operation for him?

Alternatives?Any preop requirements?Counseling regarding risks? Laparoscopic vs. open?

INDEX OPERATION• 5/13/2009•Lap converted to open RYGB• 2.5 hours enterolysis• 150 cm Roux, 15 ml pouch, GIA proximal anastomosis, retrocolic and retrogastric Roux limb•Drain and distal G tube

POD 1-3• Intraop and POD 1 swallow no leak, liquids start POD 1•Complains of back pain (has since recovery), worse POD 3, very vocal•POD 3: tachycardia to 120, note milky colored fluid from drain

REOPERATION• Quart cloudy fluid LUQ, subhepatic space• Leak from proximal pouch staple line• Oversewn, no leak intraop, two more drains added, same distal G tube retained•Next steps in management?

POD 4/7Drain puts out more milky fluid

Temp to 38.7Swallow: persistent leakNext steps?

LEAK CONTROL• CT scan: no new fluid collections•UGI: leak into drains• GI endo: attempts to stent unsuccessful: leak from pouch not anastomosis• 1 cm hole evident on endoscopy• Clips placed, not effective•Next steps?

THE PERSISTENT LEAKTwo months, repeat swallow studies q 3 weeks, persistent leak times two then reports decreased leakage of 10-15 ml per drain per day

GASTROGASTRIC FISTULANow 11 weeks postop, wt loss of 80 pounds (wt 380), persistent pain requiring high dose narcotics, admits to taking liquids

Treatment?Choices?

GASTROGASTRIC FISTULA• Drains removed serially in clinic• UGI: contained leak, into lower stomach• PO diet advanced without problems• Remaining drains out by 4 mos postop• G tube out• Wt loss continues, nutrition fair with marginal protein, narcotic demands major issue

1 YEAR CHECKUP•Weight at 250 from 460•Has incisional hernia•Wants abdominoplasty•Narcotic abuse continues• Complains of persistent epigastric nonspecific pain, unaffected by eating•Nutritional parameters OK•What would you do?

PO month 16: UH OH!•Three weeks before scheduled abdominoplasty/hernia repair presents with 5 cm swollen subcutaneous abscess left upper flank and back•Drain: GI organisms, fungus on culture•Next steps?

RECURRENT GASTROCUTANEOUS FISTULA•Hospitalized, IV antibiotics and antifungals•Daily low grade fever, pain•NPO•Reoperation??•What should we do at surgery?

REOPERATION FOR FISTULA•Difficult dissection•Excised slice from lower gastric remnant to eliminate fistula•Repaired hole in proximal pouch staple line: intraop leak test negative with pressure•More drains, new G tube

RECURRENT PROBLEMSPOD 5: wound becomes erythematous, draining foul-smelling enteric contents

UGI: persistent leak, gastrocutaneous fistula to wound

What would you do next?

ANOTHER REOPERATION• Damage control surgery• Explored upper abdomen: everything densely scarred in, fistula directly upward from stomach pouch to wound• Large drains in tract, wound debrided, closed around fistula and drains with retention sutures• Any other management ideas?

STENT REVISITED• In order to try and control degree of fistula volume, stent placed• Did decrease volume of output• Fistula tract drains “fell out” several days later, bedside Mallekot inserted into tract, controlled output•Wound healed, Mallekot in place• Distal G tube feedings for nutriton

PERSISTENT FISTULAManagement steps now?Controlled fistula: would you let him take any pos?

How long to keep stent?

PERSISTENT FISTULA• Stent removed after two months (11/10)• Fistula decreased on swallow• Allowed po liquids• Return Dec 2011: drain dry, removed• Followup swallow: no leak• G tube removed Jan 2011• Scheduled for hernia repair March• No narcotics since Dec 2010

CASE 2• 1988: As a 36 yo man, weight 440, BMI 60, comorbid problems of HTN, DM2, OSA, COPD, DJD, GERD•Underwent open RYGB: undivided gastric pouch, retrocolic antegastric 150 cm Roux limb

CASE 2•Postop loses 180 pounds first year, poor followup thereafter, represents in 1995 with marginal ulcer•UGI: break in gastric staple line with gastrogastric fistula•Next step?

REOPERATIONReoperation to divide stomach successfully performed

Marginal ulcer: improved on followup EGD

No longer smokingMedical rx from here out?

RECURRENT MARGINAL ULCER• Represents in 2000 with bleeding marginal ulcer, treated endoscopically, conservatively, sx resolve• Recurrent ulcer again in 2002, 2003, and 2004• Scope by me 2004: pinhole opening gastric pouch staple line, recommend follow-up scope four months• Does not return until March 2010

MARCH 2010 VISIT•Weight back up to 420 pounds•CHF, DM2, HTN, OSA, pulmonary HTN, Grade 3 renal insufficiency, atrial fibrillation •Dietary Hx: Drinks three 2 liter bottles of Mountain Dew per day•No severe epigastric pain (on PPI)•Followed closely in endocrine, pulmonary, and cardiology clinics

ACUTE ABDOMEN5/21/10: Transferred from OSH that night after admission earlier that day. Clinical picture of septic shock picture

Hypotensive, oliguric, abdominal pain

CT scan performed

PREOP CONDITIONMedical problems: CAD, CHF, DM2 insulin, renal insuff stage 3, HTN, hyperlipidemia, OSA, probably pulm HTN, Hgb 8

Class IVEMortality risk?? Lap anyone??

INTRAOP FINDINGSSevere scarring; mucus fluid LUQ

Roux limb has no anterior wall over 2 inch area at anastomosis-looking at open bowel, stoma of mucosa in back wall, represents fistula to lower stomach

What next??

OPERATIVE PROCEDUREReasoning: Failed bariatric surgery and persistent life-threatening ulcers

Resected back Roux limb (J tube)Divided gastrogastric fistula by resecting distal stomach side

Gastrogastrostomy

MOTTO

No gastrojejunostomy, no marginal ulcer

POSTOPIn ICU 10 daysExtubated POD 6Discharged POD 16 to rehab Postop check: wounds healed, medical conditions stabilized

CASE 3:50 POUNDS OF POTATOES IN A 30 POUND SACK

Woman with spina bifidaAge 33: ileal conduitAge 51: massive abd wall parastomal hernia

PARASTOMAL HERNIARepair with large mesh, laparoscopic, in 2006: recurs

Weight 310 pounds, BMI 65Wheelchair bound2007: Urologist reports ileal conduit obstructing from the hernia

LOSS OF DOMAIN HERNIANext step?Open repair?Mesh?Component separation?Anything else?

2007 REPAIROpen approach, largest piece of Dual Mesh available

Cut out opening for ileal conduit

Failed within four months

NOW WHAT?

LOSE SOME POTATOESOpen RYGB 4/09Lost 100 pounds in one yearWt 199: open abd wall reconstruction with mesh

Reasonable repair accomplished

Ileal loop functional

CASE 443 yo male, BMI 53, known hyperlipidemia, recent DM2, mild HTN, mild DJD

Active physically, in work forceCan exercise and does so 2x/wkDieted to lose 50 pounds in 30’s

OPERATIVE CHOICE?Patient requests lap bandConcerned about the risks of RYGB

No coverage for sleeveProceed? Band type?Anything else?

UNEXPECTED CIRRHOSISNo evidence of portal hypertension

Should you proceed with band?

What if this were bypass? Sleeve? Duodenal switch?