1. STUMP THE STARS: CASE PRESENTATIONS FROM THE COMMONWEALTH
Bruce Schirmer, M.D.

2. 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

3. 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

4. OPERATIVE CHOICE Is this the right operation for him? Alternatives?
Any preop requirements?
Counseling regarding risks? Laparoscopic vs. open?

5. 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

6. 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

7. 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?

9. POD 4/7 Drain puts out more milky fluid Temp to 38.7
Swallow: persistent leak
Next steps?

10. 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?

12. THE PERSISTENT LEAK
Two months, repeat swallow studies q 3 weeks, persistent leak times two then reports decreased leakage of ml per drain per day

15. GASTROGASTRIC FISTULA
Now 11 weeks postop, wt loss of 80 pounds (wt 380), persistent pain requiring high dose narcotics, admits to taking liquids
Treatment?
Choices?

16. 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

17. 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?

18. 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?

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

22. 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

23. RECURRENT PROBLEMS
POD 5: wound becomes erythematous, draining foul-smelling enteric contents
UGI: persistent leak, gastrocutaneous fistula to wound
What would you do next?

24. 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?

26. 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

27. PERSISTENT FISTULA Management steps now?
Controlled fistula: would you let him take any pos?
How long to keep stent?

28. 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

31. 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

32. 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?

33. REOPERATION Reoperation to divide stomach successfully performed
Marginal ulcer: improved on followup EGD
No longer smoking
Medical rx from here out?

34. 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

35. 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

36. ACUTE ABDOMEN
5/21/10: Transferred from OSH that night after admission earlier that day. Clinical picture of septic shock picture
Hypotensive, oliguric, abdominal pain
CT scan performed

38. PREOP CONDITION
Medical problems: CAD, CHF, DM2 insulin, renal insuff stage 3, HTN, hyperlipidemia, OSA, probably pulm HTN, Hgb 8
Class IVE
Mortality risk?? Lap anyone??

39. INTRAOP FINDINGS Severe 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??

40. OPERATIVE PROCEDURE
Reasoning: Failed bariatric surgery and persistent life-threatening ulcers
Resected back Roux limb (J tube)
Divided gastrogastric fistula by resecting distal stomach side
Gastrogastrostomy

41. No gastrojejunostomy, no marginal ulcer
MOTTO
No gastrojejunostomy, no marginal ulcer

42. POSTOP In ICU 10 days Extubated POD 6 Discharged POD 16 to rehab
Postop check: wounds healed, medical conditions stabilized

44. CASE 3: 50 POUNDS OF POTATOES IN A 30 POUND SACK
Woman with spina bifida
Age 33: ileal conduit
Age 51: massive abd wall parastomal hernia

45. PARASTOMAL HERNIA
Repair with large mesh, laparoscopic, in 2006: recurs
Weight 310 pounds, BMI 65
Wheelchair bound
2007: Urologist reports ileal conduit obstructing from the hernia

47. LOSS OF DOMAIN HERNIA Next step? Open repair? Mesh?
Component separation?
Anything else?

48. 2007 REPAIR Open approach, largest piece of Dual Mesh available
Cut out opening for ileal conduit
Failed within four months

51. NOW WHAT?

52. LOSE SOME POTATOES Open RYGB 4/09 Lost 100 pounds in one year
Wt 199: open abd wall reconstruction with mesh
Reasonable repair accomplished
Ileal loop functional

55. CASE 4
43 yo male, BMI 53, known hyperlipidemia, recent DM2, mild HTN, mild DJD
Active physically, in work force
Can exercise and does so 2x/wk
Dieted to lose 50 pounds in 30’s

56. OPERATIVE CHOICE? Patient requests lap band
Concerned about the risks of RYGB
No coverage for sleeve
Proceed? Band type?
Anything else?

58. UNEXPECTED CIRRHOSIS No evidence of portal hypertension
Should you proceed with band?
What if this were bypass? Sleeve? Duodenal switch?