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

STUMP THE STARS: CASE PRESENTATIONS FROM THE COMMONWEALTH Bruce 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

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

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  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 oxycontintid 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?

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

  9. 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?

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

  11. 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?

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

  13. 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?

  14. 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?

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

  16. 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

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

  18. 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?

  19. 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

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

  21. 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

  22. 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, retrocolicantegastric 150 cm Roux limb

  23. 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?

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

  25. 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

  26. 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

  27. 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

  28. 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??

  29. 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??

  30. 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

  31. MOTTO No gastrojejunostomy, no marginal ulcer

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

  33. 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

  34. 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

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

  36. 2007 REPAIR • Open approach, largest piece of Dual Mesh available • Cut out opening for ileal conduit • Failed within four months

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