Papers by Rodrigo Gonzalez
Journal of The American College of Surgeons, 2007
BACKGROUND: Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of t... more BACKGROUND: Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity. STUDY DESIGN: Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed.
World Journal of Surgery, 2005
Contraction is a well-documented phenomenon occurring within two months of mesh implantation. Its... more Contraction is a well-documented phenomenon occurring within two months of mesh implantation. Its etiology is unknown, but it is suggested to occur as a result of inadequate tissue ingrowth into the mesh and has been associated with hernia recurrence. In continuation of our previous studies, we compared tissue ingrowth characteristics of large patches of polyester (PE) and heavyweight polypropylene (PP) and their effect on mesh contraction. The materials used were eight PE and eight PP meshes measuring 10 × 10 cm2. After random assignment to the implantation sites, the meshes were fixed to the abdominal wall fascia of swine using interrupted polypropylene sutures. A necropsy was performed three months after surgery for evaluation of mesh contraction/shrinkage. Using a tensiometer, tissue ingrowth was assessed by measuring the force necessary to detach the mesh from the fascia. Histologic analysis included inflammatory and fibroblastic reactions, scored on a 0–4 point scale. One swine developed a severe wound infection that involved two PP meshes and was therefore excluded from the study. The mean area covered by the PE meshes (87 ± 7 cm2) was significantly larger than the area covered by the PP meshes (67 ± 14 cm2) (p = 0.006). Tissue ingrowth force of the PE meshes (194 ± 37 N) had a trend toward being higher than that of the PP meshes (159 ± 43 N), although it did not reach statistical significance. There was no difference in histologic inflammatory and fibroblastic reactions between mesh types. There was a significant correlation between tissue ingrowth force and mesh size (p = 0.03, 95% CI: 0.05–0.84). Our results confirm those from previous studies in that mesh materials undergo significant contraction after suture fixation to the fascia. PE resulted in less contraction than polypropylene. A strong integration of the mesh into the tissue helps prevent this phenomenon, which is evidenced by a significant correlation between tissue ingrowth force and mesh size.
Surgery for Obesity and Related Diseases, 2006
Small bowel obstruction (SBO) is a well-recognized complication of bariatric surgery. Many factor... more Small bowel obstruction (SBO) is a well-recognized complication of bariatric surgery. Many factors that play a role in the etiology of SBO affect the presentation, timing, and treatment after Roux-en-Y gastric bypass (RYGB). We reviewed our experience with SBO after open and laparoscopic RYGB. We reviewed prospectively collected data from 784 consecutive patients who had undergone RYGB (458 open and 326 laparoscopic) from July 1998 to March 2005. The operative techniques were standardized, including closure of the mesenteric defects. The follow-up data were taken from clinic visit records and follow-up questionnaires. The mean follow-up period was 16 +/- 1 months (range 1-75). The data presented are the mean +/- SEM. The overall incidence of SBO after RYGB was 3.2%. Thirteen patients developed SBO after laparoscopic RYGB (4%) and 12 patients did so after open RYGB (2.6%, P = NS). Obstruction at the jejunojejunostomy was more common after laparoscopic RYGB (77%, P <.05), and adhesive SBO was more common after open RYGB (50%, P <.05). The incidence of SBO from internal hernia was low, regardless of the operative approach (open 0.7% versus laparoscopic 0.3%). Early SBO resolved with nonoperative treatment in 30% of patients. Understanding the anatomic considerations of RYGB in the development of SBO after open and laparoscopic approach is essential to timely and effective treatment.
Although perceived as a more technically demanding and time-consuming technique, the hand-sewn ga... more Although perceived as a more technically demanding and time-consuming technique, the hand-sewn gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (RYGB) is associated with fewer complications and lower costs than stapled techniques. A retrospective medical record review of prospectively collected data. University hospital. One hundred eight consecutive patients undergoing laparoscopic RYGB between January 1, 1999, and December 31, 2001. Three techniques were compared: hand-sewn anastomosis (HSA), circular-stapled anastomosis (CSA), and linear-stapled anastomosis (LSA). Operative costs, including the cost of stapling devices, the cost of sutures, and operative times, were compared. Rates of anastomotic strictures, leaks, marginal ulcers, bleeding, and wound infections were determined. Eighty-seven patients underwent HSA; 13, CSA; and 8, LSA. Supply costs per patient were higher for CSA ($955) and LSA ($435) than for HSA ($2) (P<.001). The mean +/- SEM operative time for laparoscopic RYGB was longer when performing CSA than HSA or LSA (285 +/- 22 vs 215 +/- 8 and 204 +/- 28 minutes, respectively; P<.001). Stricture rates were higher after CSA than HSA and LSA (4 [31%] of 13 patients vs 3 [3%] of 87 patients and 0 of 8 patients, respectively;…
Surgery, 2007
Background. Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to... more Background. Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to report objective improvement of obesity-related OSA and sleep quality after bariatric surgery. Methods. Prospective bariatric patients were referred for polysomnography if they scored Ն6 on the Epworth Sleepiness Scale. The severity of OSA was categorized by the respiratory disturbance index (RDI) as follows: absent, 0 to 5; mild, 6 to 20; moderate, 21 to 40; and severe, Ͻ40. Patients were referred for repeat polysomnography 6 to 12 months after bariatric surgery or when weight loss exceeded 75 lbs. Means were compared using paired t tests. Chi-square tests and linear regression models were used to assess associations between clinical parameters and RDI; P Ͻ .05 was considered statistically significant. Results. Of 349 patients referred for polysomnography, 289 patients had severe (33%), moderate (18%), and mild (32%) OSA; 17% had no OSA. At a median of 11 months (6 to 42 months) after bariatric surgery, mean body mass index (BMI) was 38 Ϯ 1 kg/m 2 (P Ͻ .01 vs 56 Ϯ 1 kg/m 2 preoperatively) and the mean RDI decreased to 15 Ϯ 2 (P Ͻ .01 vs 51 Ϯ 4 preoperatively) in 101 patients who underwent postoperative polysomnography. In addition, minimum oxygen saturation, sleep efficiency, and rapid eye movement latency improved, and the requirement for continuous positive airway pressure was reduced (P Յ .025). Male gender and increasing BMI correlated with increasing RDI (P Ͻ .01) by chi-square analysis. In a multivariate linear regression model adjusted for age and gender, preoperative BMI correlated with preoperative RDI (r ϭ 0.27; P Ͻ .01). Conclusions. OSA is prevalent in at least 45% of bariatric surgery patients. Preoperative BMI correlates with the severity of OSA. Surgically induced weight loss significantly improves obesity-related OSA and parameters of sleep quality. 141:354-8.) From the
Diseases of The Colon & Rectum, 2006
Introduction Laparoscopic procedures converted to open approaches have been associated with highe... more Introduction Laparoscopic procedures converted to open approaches have been associated with higher complication rates than laparoscopic and open cholecystectomy and appendectomy. Laparoscopic colorectal resections have relatively high conversion rates compared with other laparoscopic procedures. This study was designed to evaluate outcomes of conversions compared with laparoscopic and open colorectal resections. Methods We reviewed 498 consecutive colorectal resections performed between 1995 and 2002. Procedures were divided into laparoscopic colorectal resections, open colorectal resections, or conversions. Demographics, underlying disease, type of procedure performed, and operative outcomes were compared between groups. Results Of the 238 laparoscopic procedures performed, 182 were completed laparoscopically and 56 (23 percent) required conversion; 260 were performed open. Conversions were associated with greater blood loss (200 (range, 50–750) vs. 100 (range, 30–900) ml), longer time to first bowel movement (82 (range, 40–504) vs. 72 (range, 12–420) hr), and longer length of stay (6 (range, 2–67) vs.. 5 (range, 2–62) days) than the laparoscopic colorectal resections group. There was no difference in operative time, transfusion requirements, intraoperative and postoperative complications, or mortality between conversions and laparoscopic colorectal resections. Conversions resulted in fewer patients requiring transfusions (4 vs. 14 percent), shorter time to first bowel movement (82 (range, 40–504) vs. 93 (range, 24–240) hr), and shorter length of stay (6 (range, 2–67) vs. 7 (range, 2–180) days) than in the open colorectal resections group. There were no differences in complications or mortality between the conversion group and the open colorectal resections group. Conclusions Laparoscopic colorectal resections has a relatively high conversion rate; however, the converted cases have outcomes similar to open colorectal resections. In fact, the converted group required fewer blood transfusions than the open group. Experience and good judgment are fundamental for timely conversion of a laparoscopic procedure to open to decrease complication rates. Despite a high conversion rate, surgeons should consider laparoscopic colorectal resections, because even when necessary, conversion does not result in poorer outcomes than laparoscopic colorectal resections or open colorectal resections.
BACKGROUND: Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of t... more BACKGROUND: Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity. STUDY DESIGN: Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed.
Surgery for Obesity and Related Diseases, 2006
Obesity Surgery, 2004
The gastrojejunostomy may be the most technically challenging step when performing laparoscopic R... more The gastrojejunostomy may be the most technically challenging step when performing laparoscopic Roux-en-Y gastric bypass. Patients who develop anastomotic leaks have increased morbidity and mortality rates. Difficulty in diagnosis is related to nonspecific systemic symptoms and limitations in most radiological studies. Our aim is to evaluate the incidence, etiology, diagnosis, management, and prevention of anastomotic leaks occurring in patients undergoing laparoscopic Roux-en-Y gastric bypass.
Journal of The American College of Surgeons, 2005
Bariatric surgeons are increasingly encountering patients with failed weight-loss operations. Con... more Bariatric surgeons are increasingly encountering patients with failed weight-loss operations. Conversion from vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGB) is the most common revisional operation in our practice. We reviewed our experience in converting from VBG to RYGB using a basic five-step surgical technique. We reviewed data on all patients undergoing revisional surgery for failed VBG, defined as patients with body mass index >/=35 kg/m(2), weight gain, poor control of comorbidities, staple-line dehiscence, or band-specific complications. The five basic steps include identification of the band, delineation of the extent of the pouch, division of the stomach, preparation of the Roux limb, and completion of the cardiojejunostomy. We have undertaken 28 conversions from VBG to RYGB. Median age was 51 years (range 27 to 65 years), preoperative body mass index was 40 kg/m(2) (range 20 to 58 kg/m(2)), and 25 patients (89%) were women. Indications for revision were band-related complications (13 patients), staple-line disruption (9 patients), and inadequate weight loss (6 patients). Median operative time was 185 minutes (range 105 to 465 minutes), estimated blood loss was 450 mL (range 100 to 2,500 mL), postoperative complications occurred in 6 patients (21%), and length of hospitalization was 5 days (range 3 to 69 days). Median postoperative body mass index was 32 kg/m(2) (range 20 to 41 kg/m(2)) at a followup time of 16 months (range 1 to 32 months). The technique described facilitates the operative approach to patients with failed VBG, providing guidelines for safe dissection and division of the gastric pouch for conversion to RYGB. Revisional bariatric operations are technically difficult and are associated with relatively higher complication rates than those reported for primary operations.
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Papers by Rodrigo Gonzalez