Nathan Zundel

Bariatric Institute of Greater Chicago, Hinsdale, Illinois, United States

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Publications (9)20.65 Total impact

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    ABSTRACT: Degenerative schwannomas are rare benign tumors. The patient presented in this case report complained of a dull left upper quadrant pain for several months. A computed tomography scan revealed a low-density lesion at the level of T12. The lesion was laparoscopically resected and pathologic examination revealed a degenerative schwannoma.
    Surgical laparoscopy, endoscopy & percutaneous techniques 03/2008; 18(1):121-3. · 0.88 Impact Factor
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    ABSTRACT: Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique. The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%-93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%-2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4-6 days in most series. Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.
    World Journal of Surgery 05/2006; 30(4):535-40. · 2.23 Impact Factor
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    ABSTRACT: Background: Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. Methods: The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique. Results: The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%–93% in the literature. Conversely, 31% of scars from pre-vious surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conven-tional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%–2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparo-scopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intra-operative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4–6 days in most series. Conclusions: Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic sur-geon not only for its usefulness in the pathologies discussed here but also for adhesions com-monly encountered during other laparoscopic procedures. I ntra-abdominal adhesions cause small bowel obstruc-tion in 49%–74% of cases. 1–3 The management of intestinal obstruction is initially conservative, provided that the patient is clinically stable and without signs of systemic toxicity. Traditionally, laparotomy and adhesiol-ysis was the treatment of choice for patients who failed conservative measures or when clinical and physiologic derangements suggested toxemia and/or ischemia. 4–6 However, up to one third of patients may require re-lap-arotomy for recurrent small bowel obstruction resulting from the formation of intra-abdominal adhesions. 7–10 Furthermore, laparotomy increases the incidence of ventral hernia, wound infection, postoperative ileus, postoperative pain, and length of hospital stay. 11–13 Since the advent of minimally invasive surgery with the introduction of laparoscopic cholecystectomy in the late 1980s, the laparoscopic method continues to advance the field of general surgery. Initial contraindications to lapa-roscopy such as morbid obesity and previous abdominal surgery have since disappeared with increased experi-ence and technical advances in surgical instrumentation. These advances have also led to the application of min-imally invasive techniques to an increasing number and variety of procedures. Furthermore, recent promising re-ports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. 11,12,14,15 Laparoscopic adhesiolysis was first described in the gynecologic literature for the treatment of chronic pelvic pain and infertility. Since then, this tech-nique has been applied to the treatment of chronic abdominal pain in both adults and children. 16,17 Intra-abdominal adhesions are often well-vascular-ized and innervated, which may explain the relationship to some chronic abdominal pain syndromes. 18 The utility of laparoscopic adhesiolysis has been reported for intrac-table abdominal pain in both the adult and pediatric populations. 16,17,19–21 In these cases, the procedure is not only diagnostic but also curative. Some authors 21 advocate the use of laparoscopy under local anesthesia to reproduce the pain and to identify the specific adhesion causing the pain. Others have concluded that, although laparoscopic adhesiolysis relieves chronic abdominal pain, it is not more beneficial than diagnostic laparoscopy alone and cannot be recommended as a treatment for adhesions in these patients. 22 Bastug et al. 23 reported the first case of laparoscopic adhesiolysis for small bowel obstruction. Subsequently, several case reports and multiple series have reported the success of laparoscopic adhesiolysis. 15,24 Despite these data, laparoscopic adhesiolysis for small bowel obstruction still remains a concern for surgeons, and it has yet to gain widespread acceptance. The purpose of this review was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips for operating with this technique.
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    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. Methods: The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique. Results: The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%–93% in the literature. Conversely, 31% of scars from pre-vious surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conven-tional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%–2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparo-scopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intra-operative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4–6 days in most series. Conclusions: Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic sur-geon not only for its usefulness in the pathologies discussed here but also for adhesions com-monly encountered during other laparoscopic procedures. I ntra-abdominal adhesions cause small bowel obstruc-tion in 49%–74% of cases. 1–3 The management of intestinal obstruction is initially conservative, provided that the patient is clinically stable and without signs of systemic toxicity. Traditionally, laparotomy and adhesiol-ysis was the treatment of choice for patients who failed conservative measures or when clinical and physiologic derangements suggested toxemia and/or ischemia. 4–6 However, up to one third of patients may require re-lap-arotomy for recurrent small bowel obstruction resulting from the formation of intra-abdominal adhesions. 7–10 Furthermore, laparotomy increases the incidence of ventral hernia, wound infection, postoperative ileus, postoperative pain, and length of hospital stay. 11–13 Since the advent of minimally invasive surgery with the introduction of laparoscopic cholecystectomy in the late 1980s, the laparoscopic method continues to advance the field of general surgery. Initial contraindications to lapa-roscopy such as morbid obesity and previous abdominal surgery have since disappeared with increased experi-ence and technical advances in surgical instrumentation. These advances have also led to the application of min-imally invasive techniques to an increasing number and variety of procedures. Furthermore, recent promising re-ports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. 11,12,14,15 Laparoscopic adhesiolysis was first described in the gynecologic literature for the treatment of chronic pelvic pain and infertility. Since then, this tech-nique has been applied to the treatment of chronic abdominal pain in both adults and children. 16,17 Intra-abdominal adhesions are often well-vascular-ized and innervated, which may explain the relationship to some chronic abdominal pain syndromes. 18 The utility of laparoscopic adhesiolysis has been reported for intrac-table abdominal pain in both the adult and pediatric populations. 16,17,19–21 In these cases, the procedure is not only diagnostic but also curative. Some authors 21 advocate the use of laparoscopy under local anesthesia to reproduce the pain and to identify the specific adhesion causing the pain. Others have concluded that, although laparoscopic adhesiolysis relieves chronic abdominal pain, it is not more beneficial than diagnostic laparoscopy alone and cannot be recommended as a treatment for adhesions in these patients. 22 Bastug et al. 23 reported the first case of laparoscopic adhesiolysis for small bowel obstruction. Subsequently, several case reports and multiple series have reported the success of laparoscopic adhesiolysis. 15,24 Despite these data, laparoscopic adhesiolysis for small bowel obstruction still remains a concern for surgeons, and it has yet to gain widespread acceptance. The purpose of this review was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips for operating with this technique.
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    ABSTRACT: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.
    Surgery for Obesity and Related Diseases 01/2006; 2(2):87-91. · 4.12 Impact Factor
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    ABSTRACT: Access port site hernia is a rare complication associated with the laparoscopic adjustable gastric band (LAGB). Specifically, this unique problem occurs when a fascial defect allows herniation adjacent to the Silastic tubing connects the LAGB to the access port. A 48-year-old woman who had previously undergone placement of LAGB presented with a bulge lateral to the access port; physical examination revealed a hernia near the access port. At laparoscopy, a large portion of omentum was herniated lateral to the Silastic tubing at the port site. This was laparoscopically repaired by first reducing the omentum and then placing a surgical mesh underlay to cover the defect; the patient recovered uneventfully. Access port site hernia is a rare complication with only a single case report published in the literature. We present a case of access port site hernia that was laparoscopically repaired. In addition, we have identified several important technical aspects that may contribute to the development of access port site hernias.
    Surgical laparoscopy, endoscopy & percutaneous techniques 07/2005; 15(3):174-6. · 0.88 Impact Factor
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    ABSTRACT: Esophageal perforation is a serious complication that requires prompt recognition and treatment. We present the case of a patient with lower esophageal perforation that apparently resulted from orogastric calibration-tube passage during laparoscopic placement of a gastric band. The complication was diagnosed early postoperatively, and was able to be successfully treated by laparoscopy,debanding, drainage, and parenteral nutrition.
    Obesity Surgery 04/2004; 14(3):422-5. · 3.10 Impact Factor
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    ABSTRACT: The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.
    Obesity Surgery 01/2004; 13(6):842-7. · 3.10 Impact Factor
  • Surgery for Obesity and Related Diseases 1(5):503-5. · 4.12 Impact Factor