Laparoscopic Sleeve Gastrectomy in patients with Idiopathic Intracranial Hypertension (IIH).

Commentary on Management of Intraabdominal Catheters during Bariatric Surgery

Cases by Dr. Tamer N. Abdelbaki, Commentary by Prof. Ankit Patel and Dr. Ann Marie Defnet

Cases (Dr. Abdulbaki)

We here in report our experience with three patients suffering from Idiopathic Intracranial Hypertension who had bariatric surgery at our hospital.

Case 1:

A 35 y old female with a long history of disabling headaches and blurring of vision. She was referred to the ophthalmologist and after work up (Case 1, Figure 1, 2, 3), she was diagnosed with Post Papilledemic Bilateral Optic Atrophy. She subsequently lost her vision.

Case 1, Figure 1

Case 1, Figure 2

Case 1, Figure 3

CT & MRI brain were ordered by Neurology clinic and was otherwise normal except for a posterior fossa Arachnoid cyst. She was then subjected to series of Lumbar punctures (Case 1, Figure 4, 5, 6) and when symptoms weren’t improving and LP opening pressure reached 62 cm CSF patient was scheduled for Lumbo-peritoneal Shunt.

Case 1, Figure 4

Case 1, Figure 5

Case 1, Figure 6

Her symptoms improved a little bit but the shunt was non-functioning owing to her severe obesity. So she was referred to our hospital for Bariatric Surgery. Her weight was 130 kg with a height of 1.67 (BMI 46.6) Central Obesity; WHR: 0.9. At the time of presenation she complained of worsening headaches, some mild light perception with a wandering gaze and a total loss of visual acuity. She was subsequently scheduled for Laparoscopic Sleeve Gastrectomy. During her surgery we could barely see the shunt buried deep in the omentum and it was not functioning owing to the increased intraabdominal pressure (Case 1, Figure 7).

Case 1, Figure 7

Immediately after surgery she wasn’t complaining of headaches and later after five months after her surgery she lost 45 kg and dramatically had a sudden regain of her vision (Case 1, Figure 8,9) .

Case 1, Figure 8

Case 1,Figure 9

One year later the patient developed gall stones. So she came back for surgery and during the procedure we noticed a considerable amount of CSF fluid intraperitoneally denoting a regain in function of the Lumbo-peritoneal shunt (Case 1, Figure 10).

Case 1, Figure 10

Currently, the patient is 3 years out from LSG with BMI of 25 (lost 55 kg). Patient has now tubular vision with good perception of light and walks unassisted.

Case 2:

A 33 year old female patient at a weight of 97 kg and height of 1.53 m (BMI 40) She was diagnosed with IIH 5 years ago when she used to complaint of severe daily headaches and early morning blurring of vision and nausea. She had a LP opening pressure of 40 cm CSF. She was urgently operated on with a Lumbo(theco)-peritoneal shunt. After shunt placement she no longer complained of blurring of vision but headaches still persisted with a lower frequency (3 times per week). She then came to our hospital for bariatric surgery in an attempt to control her symptoms. She had a Laparoscopic Sleeve Gastrectomy (Case 2, Figure 1, 2). Within the first week of surgery she was free from any headaches. She is now 1 month from surgery and already lost 15 kgs.

Case 2, Figure 1

Case 2, Figure 2

Case 3:

A 32 year old female at a weight of 150kg and height of 1.68 m (BMI 53) she was complaining of frequent severe headaches that was not responding to analgesics. She then started to develop blurring of vision on which she was referred to an ophthalmologist who did a retinal exam and found bilateral papilledema. She was then referred to neurology who ordered a CT scan and Lumbar puncture (LP). Patient described that it was very difficult to perform the LP and that they struggled to get a sample and test the opening pressure of the tap because of her severe obesity. She was then diagnosed with IIH and was prescribed a carbonic anhydrase inhibitor ( acetazolamide) to lower her Intracranial pressure. She developed some reactions with her new medications so she wasn’t consistently compliant with the medications and therefore symptoms persisted. She was then referred to us for bariatric surgery. She had a Laparoscopic Sleeve Gastrectomy and her surgery was uneventful. She is now 3 months post-surgery and is down to 115 kg and is no longer suffering from headaches or blurring of vision. Her last fundus examination was completely normal.

The above series of patients are proof of how weight loss can be a cornerstone in the long term management of IIH and how bariatric surgery can induce dramatic improvement in the quality of life of those patients.

Commentary on Management of Intraabdominal Catheters during Bariatric Surgery (Prof. Ankit Patel and Dr. Ann Marie Defnet)

In this issue, Dr. Abdelbaki described improvement in symptoms of three patients with idiopathic intracranial hypertension (IIH) after bariatric surgery. Two of these patients had lumbo-peritoneal shunts for management of their increased intracranial pressure. The management of patients with intraperitoneal shunts or peritoneal dialysis catheters who undergo laparoscopic bariatric surgery is not completely described in the literature. Here we review the available literature on the care of these patients, and describe our opinion for optimal care.

There is evidence in the literature, as also shown in Dr. Abdelbaki’s case report, of improvement in IIH in patients with ventriculoperitoneal (VP) shunts who have weight loss associated with bariatric surgery. In a 2017 paper, Hoang, et al. reported shunt freedom or increased settings in 3 pediatric patients who underwent laparoscopic bariatric surgery, and given this improvement suggested considering bariatric surgery in the treatment algorithm for patients with severe IIH with obesity (1). In their case series there were no infectious, neurological, or other complications secondary to bariatric surgery, which included both sleeve gastrectomy and roux-en-y gastric bypass. Several isolated case reports also exist in the neurosurgery literature that show that weight loss does help with management of IIH and favor referring patients with IIH for bariatric surgery.

As a result, technical issues regarding laparoscopic surgery in patients with VP shunts should also be discussed. There is risk for elevated intracranial pressure during insufflation given an open system between the peritoneum and ventricular system, although multiple case reports reveal no neurological deficits in patients with VP shunts who undergo laparoscopic surgery. This includes with or without occlusion of the peritoneal end of the catheter during insufflation in attempt to prevent pressure transmittal (2-5). Jackman, et al. reported a case series of 18 patients with VP shunts who underwent laparoscopic surgery, and found that there were no neurological deficits reported postoperative with 3h of insufflation at an average of 16mmHg, without shunt occlusion (4). These recommendations can be seen in the literature regarding performing laparoscopic surgery on patients with VP shunts to prevent elevated ICP (6). In general, if these parameters can be met, patients with VP shunts should not need externalization or other procedures related to elevated intracranial pressure or their VP shunts when undergoing laparoscopic bariatric surgery, but should have adequate monitoring post operatively to monitor their neurological status. Bariatric surgery should also be considered in patients with severe IIH who are obese to aim to treat the IIH itself.

The discussion of laparoscopic surgery on patients with peritoneal dialysis (PD) catheters raises a different set of concerns, most notably infection of the catheter, and when and how to resume PD after laparoscopic surgery itself. A review of laparoscopic surgery in patients on PD by Mari, et al. revealed only a few reports of laparoscopic bariatric surgery on patients on PD (7). Given concern for catheter infection, these authors recommend extended perioperative antibiotic prophylaxis, although no bariatric patients reported in the literature had catheter infection or peritonitis post operatively (7-9).

There is also no consensus regarding the reinstitution of PD post operatively after laparoscopic bariatric surgery (or any other major operations). The first case report in the literature of laparoscopic sleeve gastrectomy on a patient on PD described low-volume exchanges the first 2 weeks post operatively, with the addition of a 1L final fill during weeks 3 and 4 (8). The patient’s full pre-surgical PD regimen was implemented after 4 weeks without fluid leakage, pain, or other surgical complications. Another case series also reported resumption of PD on post op day 1 in 4 patients with a volume titration protocol which allowed a 25-50% dwell volume for the first 3-5 days post operatively, with a 25% volume increase daily every 3-5 days thereafter until the pre surgical dwell volume was achieved (9). They noted no fluid leakage or other complications secondary to PD. In our practice, we have employed a temporary period of hemodialysis for 4 weeks to allow for adequate healing of the laparoscopic sites, as well as decreased risk for infection, before resuming PD. This timing was shown in cases of major laparoscopic surgical procedures such as colectomy to have produced safer outcomes, and was recommended for minor surgical procedures as well by Mari, et al. in their review (7). Most nephrologist also support this practice and rarely push to resume therapy unless there are issues with vascular access or hemodialysis.

In conclusion, laparoscopic bariatric surgery appears to be safe, and even beneficial, for patients with both VP shunts and PD catheters, frequently allowing VP shunt freedom with resolution of symptoms of IIH or kidney transplant for end-stage renal disease requiring PD after significant weight loss. For patients with VP shunts, we recommend short insufflations times with minimal insufflation pressure to avoid possible intraoperative increased in intracranial hypertension. For patients with PD catheters, we recommend a 4 week period of hemodialysis before resuming PD as the safest regimen. In all of these patients, perioperative antibiotics could be extended given increased risk of infection, and patients should have increased monitoring related to the presence of these catheters to timely treat any postoperative complications that may arise.

References

Hoang KB, Hooten KG, Muh CR. Shunt freedom and clinical resolution of idiopathic intracranial hypertension after bariatric surgery in the pediatric population: report of 3 cases. J Neurosurg Pediatr 20:511-516, 2017.Wadhwa S, Hanna GK, Barina AR, Audisio RA, Virgo KS, Johnson FR. Gastrointestinal cancer surgery in patients with a prior ventriculoperitoneal shunt: the department of veterans affairs experience. Gastrointest Cancer Res 2012;5:125-9.Kerwat RM, Murali Krishnan VP, Appadurai IR, Rees BI. Laparoscopic cholecystectomy in the presence of a lumbo-peritoneal shunt. J Laparoendosc Adv Surg Tech A 2001;11:37-9.Jackman SV, Weingart JD, Kinsman SL, Docimo SG. Laparoscopic surgery in patients with ventriculoperitoneal shunts: safety and monitoring. J Urol 2000;164:1352-4.Al-Mufarrej F, Nolan C, Sookhai S, Broe P. Laparoscopic procedures in adults with ventriculoperitoneal shunts. Surg Laparosc Endosc Percutan Tech 2005;15:28-29.Sankpal R, Chandavarkar A, Chandavarkar M. Safety of Laparoscopy in Ventriculoperitoneal shunt patients. J Gynecol Endosc Surg 2011;2(2):91-93.Mari G, Scanziani R, Auricchio S, Crippa J, Maggioni D. Laparoscopic surgery in patients on peritoneal dialysis: a review of the literature. Surg Innov 2017;24(4):397-401.Imam TH, Wang J, Khayat FS. Bariatric surgery in a patient on peritoneal dialysis. Perit Dial Int. 2013;33:710-711.Valle GA, Kissane BE, de la Cruz-Munoz N. Successful laparoscopic bariatric surgery in peritoneal dialysis patients with interruption of their CKD6 treatment modality. Adv Perit Dial. 2012;28:134-139.

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Tamer N. Abdelbaki MD, MRCS, PhD

Lecturer of Surgery

Alexandria University Faculty of Medicine

Alexandria, Egypt

Ankit D. Patel, MD, FACS

Assistant Professor of Surgery

Division of General and GI Surgery

Emory University School of Medicine

Atlanta, USA

Ann Marie Defnet, MD

Minimally Invasive and Advanced GI Surgery Fellow

Emory Healthcare

Atlanta, USA