Bariatric Surgery in Patients with Cirrhosis: Careful Patient and Surgery-Type Selection Is Key to Improving Outcomes

PURPOSE

Previous reports suggest an increased mortality in cirrhotic patients undergoing bariatric surgery (BS). With advancements in management of BS, we aim to study the trends, outcomes, and their predictors in patients with cirrhosis undergoing BS.

MATERIALS AND METHODS

A retrospective study was performed using the National Database from 2008 to 2013. Outcomes of BS in patients with cirrhosis were studied. In-hospital mortality, length of stay, and cost of care were compared between patients with no cirrhosis (NC), compensated cirrhosis (CC), and decompensated cirrhosis (DC). Multivariable logistic regression analysis was performed to study the predictors of mortality.

RESULTS

Of the 558,017 admissions of patients who underwent BS during the study period, 3086 (0.55%) had CC and 103 (0.02%) had DC. An upward trend of vertical sleeve gastrectomy (VSG) utilization was seen during the study period. On multivariate analysis, mortality in CC was comparable with those in NC (aOR 1.88; CI 0.65-5.46); however, it was higher in DC (aOR 83.8; CI 19.3-363.8). Other predictors of mortality were older age (aOR 1.06; CI 1.04-1.08), male (aOR 2.59; CI 1.76-3.81), Medicare insurance (aOR 1.93; CI 1.24-3.01), lower income (aORs 0.44 to 0.55 for 2nd to 4th income quartile vs. 1st quartile), > 3 Elixhauser Comorbidity Index (aOR 5.30; CI 3.45-8.15), undergoing Roux-en-Y gastric bypass as opposed to VSG (aOR 3.90; CI 1.79-8.48), and centers performing < 50 BS per year (aOR 5.25; CI 3.38-8.15). Length of stay and hospital cost were also significantly higher in patients with cirrhosis as compared with those with NC.

CONCLUSION

Patients with compensated cirrhosis can be considered for bariatric surgery. However, careful selection of patients, procedure type, and volume of surgical center is integral in improving outcomes and healthcare utilization in patients with cirrhosis undergoing BS.

The Long-Term Impact of Bariatric Surgery on Development of Atrial Fibrillation and Cardiovascular Events in Obese Patients: An Historical Cohort Study

Objective: To determine whether early Roux-en-Y gastric bypass surgery (RYGB) reduces the risk of Major adverse cardiovascular events (MACE) in patients with obesity. Patients and Methods: We conducted a study of patients with class II and III obesity [body mass index (BMI) > 35 kg/m²] from Olmsted County, Minnesota, who underwent obesity clinic consultation between the years 1993-2012, and had either RYGB surgery within 1 year (RYGB-1Y group), or medically managed (No-RYGB group). The composite endpoint of MACE (all-cause mortality, stroke, heart failure admission and acute myocardial infarction) was the primary endpoint, with new-onset AF as the secondary endpoint. Results: Of the 1,009 study patients, 308 had RYGB-1Y and 701 were medically managed (No-RYGB). Overall, the age was 44.0 ± 12.4 (mean ± SD) years; BMI was 45.0 ± 6.8 kg/m². The RYGB-1Y group had a lower rate of MACE (adjusted hazard ratio (HR), 0.62; 95% CI, 0.44-0.88; P = 0.008) and lower mortality (adjusted HR, 0.51; 95% CI, 0.26-0.96; P = 0.04) than the No-RYGB group. The RYGB-1Y surgery was not associated with lower AF occurrence (HR, 0.66; 95% CI, 0.40-1.10; P = 0.11). Conclusion: An early RYGB approach for BMI reduction was associated with lower rates of MACE.

Is Roux Loop a Solution to Delayed Gastric Emptying Following Pancreaticoduodenectomy? A Single Institute Analysis

Delayed gastric emptying is one of the most common complications of pancreaticoduodenectomy (PD). It almost always results in delayed oral intake, prolonged hospital stays, and a delay in initiation of vital adjuvant treatment. A few earlier studies suggested that delayed gastric emptying (DGE) rates were better with the Roux-en Y reconstruction, but Indian literature regarding this is lacking. In our institutional study, we compared the traditional single-loop reconstruction (SL group), with the Roux loop reconstruction (RY group) following a subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). A retrospective comparative study was conducted between the conventional single loop and a Roux-en-Y method of reconstruction following a subtotal stomach preserving pancreaticoduodenectomy (SSPPD). Sixty-three consecutive Whipple's procedures were analyzed for multiple clinical parameters like removal of Ryles tube, tolerance of liquid diet and solid diet, delayed gastric emptying, duration of hospital stay and interval between surgery, and initiation of adjuvant treatment. Forty-one patients in the SL group were compared with 22 patients in the RY group. Ryles tube removal (POD 8.2 versus 2.25, p < 0.001), initiation of liquid diet (POD 8.43 versus 2.88, p < 0.001), post-operative hospital stay (13.5 days versus 9.63, p < 0.001), and interval between surgery and adjuvant treatment (37.75 days versus 28.88 days, p < 0.002) were all in favor of the RY group. The delayed gastric emptying was also found to be significantly better in the Roux-en-Y surgery group (p < 0.001). The Roux loop reconstruction following a stomach-preserving pancreaticoduodenectomy (SSPPD) is superior to single-loop reconstruction with respect to delayed gastric emptying. The lesser duration of hospital stay and early initiation of adjuvant therapy are an additional benefit of the Roux loop reconstruction.

A giant choledochal cyst: A case reported from Tanzania

INTRODUCTION

Choledochal cyst is a rare common bile duct malformation that usually presents in the pediatric group with abdominal pain, distension, and jaundice. The pathophysiology remains unclear for the cause, and surgery aims to restore biliary enteric drainage.

CASE PRESENTATION

We present a six-year-old female who presented with gradual abdominal distention associated with jaundice. Abdominal ultrasound was suggestive of choledochal cyst, and CT-scan confirmed the diagnosis. She was operated on successfully and fared well.

CONCLUSION

Choledochal cysts are a rare entity of common bile duct malformations and should be considered as a differential diagnosis in the pediatric age group. Diagnosis can be easily made by non-invasive and in-expensive radiologic modalities like ultrasonography in resource-limited settings.

Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

METHODS

A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

RESULTS

Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

DISCUSSION

Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

Bariatric Surgery and Type 2 Diabetes Remission Rates: a Retrospective Cohort Study Comparing Military Veterans and Beneficiaries

PURPOSE

The disease burden of type 2 diabetes (T2D) costs the military healthcare system an estimated $1.66 billion annually. Thirty-four percent of veterans and 28% of military beneficiaries are obese, a common feature of T2D. Bariatric surgery is a viable treatment for T2D, whether if long-term remission of T2D post-bariatric surgery occurs remains unknown. The purpose of this study was to assess differences between outcomes of veterans and military beneficiaries following bariatric surgery.

MATERIALS AND METHODS

A retrospective cohort study assessed retirees and beneficiaries diagnosed with T2D who had bariatric surgery between 2005 and 2015. Outcomes included T2D remission and vitamin and mineral deficiencies each year for 5 years post-op, analyzed via ANOVA.

RESULTS

Ninety-one patients, 46 beneficiaries and 45 retirees, were included with a mean age of 51 and 57, respectively. No significant differences between T2D remission and vitamin/mineral deficiencies 5 years post-op were found between groups. Patients with uncontrolled diabetes before surgery were less likely to achieve T2D remission for all 5 years post-op, regardless of military affiliation (p < .05).

CONCLUSION

Veterans do not have better rates of T2D remission or weight loss following bariatric surgery than other populations. Control of T2D pre-surgery is a potential clinical indicator of T2D remission success following bariatric surgery.

Comparative analysis of robotic versus laparoscopic Roux-en-Y gastric bypass in severely obese patients

Benefits of robotic surgery for Roux-en-Y gastric bypass (RYGB) are still debated. We aimed to compare conventional laparoscopic (L-RYGB) to robotic RYGB (R-RYGB) and evaluate safety, efficacy, advantages and drawbacks of each procedure. A prospective cohort study with a retrospective review approach was conducted to analyze results of L-RYGB and R-RYGB performed at a bariatric center of excellence. Patient demographics, perioperative data, weight loss, comorbidities evolution and cost were assessed. One hundred and sixty-one severely obese patients underwent R-RYGB and L-RYGB, respectively. Patient's characteristics were similar between groups. Intraoperative blood loss was similar (p = 0.91), with no requirement for blood transfusion. Median operative time was significantly reduced for R-RYGB (127 vs 160 min; p < 0.001). Seven patients (11.4%) in the L-RYGB group and 15 patients (15%) in the R-RYGB group had early postoperative complications (p = 0.63), with more anastomotic leaks and stenosis for R-RYGB during initial learning curve (p = NS). Mortality was null. Median length of hospital stay was similar (6 days; p = 0.20). Mean hospital cost was non-significantly increased for R-RYGB ($5730 vs. $4879; p = 0.34). Two years after surgery, median BMI and mean EWL% were similar for both groups (26.1 vs 26.5 kg/m² and 89.9% vs 90.9% for L-RYGB and R-RYGB groups, respectively; p = 0.71 and 0.85, respectively), with no statistically significant difference in comorbidities between the two groups (p = 0.80). R-RYGB is feasible and safe within the reach of every laparoscopic surgeon. In our series, it was associated with shorter operative time and equivalent length of stay and weight loss outcomes compared to L-RYGB. Further well-designed randomized studies are necessary to draw safe conclusions.

Revision procedures after initial Roux-en-Y gastric bypass, treatment of weight regain: a systematic review and meta-analysis

Morbid obesity is a global chronic disease, and bariatric procedures have been approved as the best method to control obesity. Roux-en-Y gastric bypass is one of the most common bariatric surgeries in the world and has become the gold standard procedure for many years. However, some patients experience weight regain or weight loss failure after the initial bypass surgery and require revisional or conversional interventions. International databases including PubMed, International Scientific Indexing (ISI), and Scopus were considered for a systematic search of articles that were published by 5th of May 2020. Forty-one published studies, which reported revision procedure on 1403 patients, were selected and analyzed for this review. The selected studies were categorized into six groups of revision procedures, including laparoscopic pouch resizing and/or revision of gastro-jejunal anastomosis (GJA), adjustable or non-adjustable gastric band over pouch ± pouch/GJA resizing, endoscopic revision of gastric GJA ± pouch, distal Roux-en-Y gastric bypass (DRGB), biliopancreatic diversion with duodenal switch (BPD-DS) or single anastomosis duodeno-ileal bypass with gastric sleeve (SADI-S), DRGB + Band or pouch/GJA resizing. Revision procedures result in more weight loss after the initial weight loss procedures. In the one-year follow-up, DRGB by itself with standardized mean difference (SMD) of  - 1.24 presented a greater decrease in body mass index (BMI). DRGB plus band or pouch/GJA resizing, BPD-DS or SADI, adjustable or non-adjustable gastric banding over pouch ± pouch/GJA resizing, endoscopic pouch and/or GJA revision and laparoscopic pouch or/and GJA resizing revealed a lower decrease in BMI in order, respectively. In the three-year follow-up, BPD-DS or SADI-S method with SMD of  - 1.40 presented the highest decrease in BMI. In follow, DRGB alone, adjustable or non-adjustable gastric banding over gastric pouch ± pouch / GJA resizing, DRGB + Band or gastric pouch/GJA resizing, laparoscopic pouch and/or GJA resizing and endoscopic revision of pouch and/or GJA revealed less reduction in BMI, respectively. In the five-year follow-up, DRGB alone procedures with SMD of  - 2.17 presented the greatest reduction in BMI. Subsequently, BPD-DS or SADI-S, laparoscopic pouch and/or GJA size revision, and endoscopic revision of GJA/pouch revealed less overall decrease in BMI in order. All methods of revision procedures after the initial RYGB have been effective in the resolution of weight regain. However, based on the findings in this systematic review, it seems DRGB or BPD-DS/SADI-S is the most effective procedure in the long-term follow-up outcome. More studies with a higher number of patients and even longer follow-ups will be required to obtain more accurate data and outcome.

Ketamine infusion reduces narcotic requirements following gastric bypass surgery: a randomized controlled trial

BACKGROUND

As the obesity epidemic worsens, anesthesiologists should expect to see more obese patients presenting for surgical procedures. Opioids cause respiratory depression, which has caused complications in patients with obstructive sleep apnea. Opioids can also cause nausea, prolonging the time that patients spend in the postanesthesia care unit. Ketamine is a potential analgesic alternative that may have advantages to narcotics in the bariatric population.

OBJECTIVES

To determine whether an intraoperative ketamine infusion would reduce postoperative narcotic use in patients during the first 48 hours after laparoscopic gastric bypass.

SETTING

Major academic medical center.

METHODS

There were 54 participating patients. The intervention group (n = 27) was randomized to receive 100 μg of fentanyl with anesthesia induction, then a 20-mg bolus of ketamine, followed by a 5 μg/kg/min intraoperative ketamine infusion starting after anesthesia induction and ending after wound closure commenced. The control group (narcotic only, n = 27) also received 100 μg of fentanyl at anesthesia induction and intraoperative boluses of fentanyl at the discretion of the anesthesia team, with .3 mg of hydromorphone administered approximately 45 minutes before the completion of surgery.

RESULTS

At 24 hours, the mean morphine-equivalent units (MEUs) were 12.7 (standard deviation [SD], 9.9; 95% confidence interval [CI], 8.8-16.6) for the ketamine group (n = 28) and 16.5 (SD, 9.8; 95% CI, 12.6-20.4) for the control group (n = 28). At 48 hours, the MEUs were 16.7 (SD, 12.0; 95% CI, 11.9-21.4) for the ketamine group and 22.7 (SD, 14.9; 95% CI, 16.8-28.6) for the control group. Cumulative MEUs for 24 hours (P = .039) and 48 hours (P = .058) postoperatively were lower in the ketamine group compared with the narcotic-only (control) group, although the difference at 48 hours did not reach statistical significance. Compared with the narcotic-only group, the ketamine group used 26% fewer MEUs after 24 hours and 31% fewer MEUs after 48 hours. This difference can mostly be attributed to group differences during the first 6 hours after surgery.

CONCLUSIONS

Ketamine successfully reduced the amount of opioids required to control bariatric patients' pain at 24 hours postoperatively, but not over the 48-hour postoperative period.

Endoscopic detorsion for early postoperative Roux limb torsion after laparoscopic gastrectomy: A case report and literature review

Various types of obstruction can occur after a gastrectomy for gastric cancer. If proper treatment is not performed, such obstructions can lead to serious conditions. Early postoperative Roux limb torsion is a rare complication, and few reports of endoscopic treatment for this complication have been made. In the present report, we describe the endoscopic detorsion of Roux limb torsion in two patients. The first case was a 77-year-old woman who underwent a laparoscopic distal gastrectomy with Roux-en-Y (R-Y) reconstruction for early gastric cancer and a laparoscopic ileocecal resection (ICR) for early colorectal cancer. On the 12^th day after the gastrectomy, a Roux limb torsion was observed. Endoscopic detorsion was performed, and the patient recovered. She was discharged on postoperative day 40. The second case was a 73-year-old man who underwent a laparoscopic-assisted total gastrectomy with a R-Y reconstruction for early gastric cancer. On the 8^th day after the gastrectomy, a Roux limb torsion occurred at the Y-shaped anastomosis (Y-anastomosis). Endoscopic detorsion was performed, and the patient recovered. He was discharged on postoperative day 17. In summary, we experienced two cases in which an endoscopic reduction of a Roux limb torsion was performed at the Y-anastomosis after gastrectomy with R-Y reconstruction. This study presents a further review of these cases and a summary of the existing literature.

Treatment of afferent loop syndrome using fluoroscopic-guided nasointestinal tube placement: Two case reports

BACKGROUND

Afferent loop syndrome (ALS) is a rare mechanical complication that occurs after reconstruction of the stomach or esophagus to the jejunum, such as Billroth II gastrojejunostomy, Roux-en-Y gastrojejunostomy, or Roux-en-Y esophagoje-junostomy. Traditionally, an operation is the first choice for benign causes. However, for patients in poor physical condition who experience ALS soon after R0 resection, the type of treatment remains controversial. Here, we present an efficient conservative method to treat ALS.

CASE SUMMARY

Case 1 was a 69-year-old male patient who underwent total gastrectomy with Roux-en-Y jejunojejunostomy. On postoperative day (POD) 10 he developed symptoms of ALS that persisted and increased over 1 wk. Case 2 was a 59-year-old male patient who underwent distal gastrectomy with Billroth II gastrojejunostomy. On postoperative day POD 9 he developed symptoms of ALS that persisted for 2 wk. Both patients underwent fluoroscopic-guided nasointestinal tube placement with maintenance of continuous negative pressure suction. Approximately 20 d after the procedure, both patients had recovered well and were discharged from hospital after removal of the tube. At 3-mo follow-up, there were no signs of ALS in these two patients.

CONCLUSION

This is the first report of treating postoperative ALS by fluoroscopic-guided nasointestinal tube placement. Our cases demonstrate that this procedure is an effective and safe method to treat ALS that relieves patients’ symptoms and avoids complications caused by other invasive procedures.

Refractory Hypocalcemia Following Stomach Intestinal Pylorus-Sparing Bariatric Surgery and Thyroidectomy: Successful Management With Creation of a Proximal Roux-en-Y Gastric Bypass

Some forms of bariatric surgery make patients susceptible to calcium malabsorption, and the parathyroid hormone (PTH) axis is important for maintaining normocalcemia in these patients. Injury to the parathyroid glands due to anterior neck surgery commonly causes PTH axis disruption and can result in severe hypocalcemia in bariatric surgery patients. Herein, we present a case of a patient with a history of stomach intestinal pylorus-sparing bariatric surgery who developed refractory hypocalcemia requiring daily intravenous (IV) calcium 2 years after thyroidectomy. PTH levels were inappropriately normal during episodes of hypocalcemia, and urinary calcium level was <3.0 mg/dL following large oral doses of calcium, suggesting that both inadequate PTH response and malabsorption contributed to her severe hypocalcemia. In order to enhance calcium absorptive capacity while minimizing the risk of weight regain, she was surgically treated with a Roux-en-Y gastric bypass proximal to the prior operation. The surgery successfully improved blood calcium levels; the patient was successfully weaned from IV calcium and was able to maintain normocalcemia with oral supplements. We discuss the case in the context of available literature and provide our recommendations.

Comparison of Billroth I, Billroth II, and Roux-en-Y reconstructions following distal gastrectomy: A systematic review and network meta-analysis

Major surgical treatment for distal gastric cancer include Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY). Since the optimal reconstruction methods remains inconclusive, we aimed to compare these treatments in terms of intraoperative and postoperative course after distal gastrectomy with a systematic review and random-effects network meta-analysis. We searched PubMed, Web of Knowledge, Ovid's database for prospective, randomized, controlled trials comparing the outcomes of BI, BII, and RY reconstruction after distal gastrectomy until January 2020. From the included studies, operative time, intraoperative blood loss, postoperative hospital stay, endoscopic findings and complications were extracted as the short- and long-term outcomes of reconstructions. The network meta-analysis was performed with R 3.5.2 software as well as "gemtc" and "forestplot" packages. Twelve randomized controlled trials (RCTs) involving 1662 patients were included. RY reconstruction has a lower risk and degree of remnant gastritis than BI and BII reconstructions(OR 0.40, 95%Crl: 0.24-0.64; OR 0.36, 95% Crl: 0.16-0.83, respectively). BI reconstruction method took significantly less time to perform as compared to BII and RY reconstruction (WMD 20, 95% Crl: 0.18-41; WMD 30, 95% Crl: 14-25, respectively). No differences in intraoperative blood loss, time to resumed oral intake, postoperative hospital stay, reflux oesophagitis and complications among the three reconstructions. The RY reconstruction after distal gastrectomy was more effective in preventing remnant gastritis than Billroth I and Billroth II reconstruction, although RY reconstruction was considered as technical complexity.

Laparoscopic Hiatal Hernia Repair and Roux-en-Y Conversion for Refractory Duodenogastroesophageal Reflux after Billroth I Distal Gastrectomy

Distal gastrectomy with Billroth I or II reconstruction may cause duodenogastroesophageal reflux (DGER), thereby resulting in digestive or respiratory symptoms. The mainstay of treatment is medication with proton pump inhibitors. However, these drugs may have limited effects in DGER. Laparoscopic fundoplication has been proven to be highly effective in treating gastroesophageal reflux disease (GERD), but it cannot be performed optimally for GERD that develops after gastrectomy. We report the case of a 72-year-old man with a history of distal gastrectomy and Billroth I anastomosis due to early gastric cancer. GERD due to bile reflux occurred after surgery and was refractory to medical therapy. The patient underwent Roux-en-Y conversion from Billroth I gastroduodenostomy and hiatal hernia repair with only cruroplasty. Fundoplication was not performed. His symptoms improved significantly after the surgery. Therefore, laparoscopic hiatal hernia repair and Roux-en-Y conversion can be an effective surgical procedure to treat medically refractory DGER after Billroth I gastrectomy.

Roux-en-Y Gastrointestinal Bypass Promotes Activation of TGR5 and Peptide YY

BACKGROUND

G protein-coupled bile acid receptor (TGR5) is involved in a number of metabolic diseases. The aim of this study was to identify the role of TGR5 after Roux-en-Y gastric bypass (GBP).

METHODS

Wild type and TGR5 knockout mice (tgr5-/-) were fed a high-fat diet (HFD) to establish the obesity model. GBP was performed. The changes in body weight and food intake were measured. The levels of TGR5 and peptide YY (PYY) were evaluated by RT-PCR, Western blot, and ELISA. Moreover, the L-cells were separated from wild type and tgr5-/- mice. The levels of PYY in L-cells were evaluated by ELISA.

RESULTS

The body weights were significantly decreased after GBP in wild type mice (p<0.05), but not tgr5-/- mice (p>0.05). Food intake was reduced after GBP in wild type mice, but also not significantly affected in tgr5-/- mice (p>0.05). The levels of PYY were significantly increased after GBP compared with the sham group (p<0.05); however, in tgr5-/- mice the expression of PYY was not significantly affected (p>0.05). After INT-777 stimulation in L-cells obtained from murine intestines, the levels of PYY were significantly increased in L-cells tgr5+/+ (p<0.05).

CONCLUSION

Our study suggests that GBP up-regulated the expression of TGR5 in murine intestines, and increased the levels of PYY, which further reduced food intake and decreased the body weight.

Propensity-score-matched analysis of a multi-institutional dataset to compare postoperative complications between Billroth I and Roux-en-Y reconstructions after distal gastrectomy

BACKGROUND

Few well-controlled studies have compared postoperative complications between Billroth I (B-I) and Roux-en-Y (R-Y). The aim of the present study was to compare the incidence of overall and severe postoperative complications by reconstruction method after distal gastrectomy.

METHODS

We performed a multi-institutional dataset study of patients who underwent distal gastrectomy with B-I or R-Y reconstruction from 2010 to 2014. Using propensity scores to strictly balance the significant variables, we compared postoperative complications between the techniques.

RESULTS

After matching, we enrolled 1014 patients (n = 507 in each group). The incidence of postoperative complications in the R-Y group was significantly higher vs the B-I group (29% vs 17%, P < 0.0001). The incidence of intra-abdominal abscess (4.3% vs 1.8%, P = 0.0177), bowel obstruction (2.6% vs 0.6%, P = 0.0203), and delayed gastric emptying (5.3% vs 1.0%, P < 0.0001) in the R-Y group was significantly higher vs the B-I group, respectively; we saw no significant difference in leakage (3.4% vs 4.1%, P = 0.5084). The incidence of grade ≥ III severe postoperative complications in the R-Y group was significantly higher vs the B-I group (13% vs 7.1%, P = 0.0013). Multivariable analysis showed that R-Y reconstruction was a strong independent risk factor for overall postoperative complications (odds ratio 1.58, P = 0.0044) and grade ≥ III severe postoperative complications (odds ratio 1.75, P = 0.0127). A forest plot revealed that R-Y reconstruction was associated with a greater risk of both overall and grade ≥ III severe postoperative complications in any subgroups.

CONCLUSIONS

R-Y reconstruction was associated with increasing overall postoperative complications, as well as severe postoperative complications.

Ineffective Absorption? Failure of Direct-Acting Therapy for Chronic Hepatitis C in Cirrhotic Patients With Roux-en-Y Gastric Bypass

In this era of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection, treated patients have extremely high rates of sustained virologic response to short courses of therapy regardless of stage of fibrosis. Treatment failure is uncommon and often attributed to medication noncompliance or viral resistance to drug. This report describes 2 Child-Pugh-A cirrhotic patients who failed to clear HCV in response to therapy with DAAs. Each patient had Roux-en-Y gastric bypass (RYGB) surgery preceding DAA therapy. RYGB may create multiple barriers to adequate DAA absorption as a result of changes in gastrointestinal physiology. Treatment monitoring and duration should be carefully considered in this unique patient population.

The Impact of Proximal Roux-en-Y Gastric Bypass Surgery on Acetaminophen Absorption and Metabolism

BACKGROUND

Roux-en-Y gastric bypass (RYGBS), a surgery that creates a smaller stomach pouch and reduces the length of small intestine, is one of the most common medical interventions for the treatment of obesity.

AIM

The aim of this study was to determine how RYGBS affects the absorption and metabolism of acetaminophen.

MATERIALS AND METHODS

Ten morbidly obese patients received 1.5 g of liquid acetaminophen (APAP) orally on three separate pharmacokinetic study days (i.e., pre-RYGBS baseline and 3 and 12 months post-RYGBS). Plasma was collected at pre-specified timepoints over 24 hours, and the samples were analyzed using liquid chromatography-mass spectrometry for APAP, APAPglucuronide (APAP-gluc), APAP-sulfate (APAP-sulf), APAP-cysteine (APAP-cys), and APAP-Nacetylcysteine (APAP-nac).

RESULT

Following RYGBS, peak APAP concentrations at the 3-month and 12-month visits increased by 2.0-fold compared to baseline (p=0.0039 and p=0.0078, respectively) and the median time to peak concentration decreased from 35 to 10 minutes. In contrast, peak concentrations of APAP-gluc, APAP-sulf, APAP-cys, and APAP-nac were unchanged following RYGBS. The apparent oral clearance of APAP and the ratios of metabolite area under the curve (AUC)-to-APAP AUC for all four metabolites decreased at 3 and 12 months post-RYGBS compared to the presurgical baseline. In a simulation of expected steady-state plasma concentrations following multiple dosing of 650 mg APAP every 4 hours, post-RYGBS patients had higher steady-state peak APAP concentrations compared to healthy individuals and obese pre-RYGBS patients, though APAP exposure was unchanged compared to healthy individuals.

CONCLUSION

Following RYGBS, the rate and extent of APAP absorption increased and decreased formation of APAP metabolites was observed, possibly due to downregulation of Phase II and cytochrome P450 2E1 enzymes.

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure

BACKGROUND

Endoscopic ultrasound-directed transgastric ERCP (EDGE) by creating an anastomosis from the gastric pouch or jejunum to the excluded stomach allows performance of ERCP in Roux-en-Y gastric bypass (RYGB) anatomy. Concern for persistent fistula following stent removal and sparse data limit adoption.

METHODS

Retrospective review of consecutive patients undergoing EDGE over a 2-year period.

RESULTS

Nineteen RYGB patients underwent EDGE; three had previously failed ERCP by the device-assisted method. Indications for ERCP were choledocholithiasis (8), recurrent acute pancreatitis (6), benign post-surgical stricture (3), elevated bilirubin, and papillary stenosis (1 each). EDGE was technically successful in all 19 patients with jejunogastric anastomosis in 11 patients and gastrogastric in 8 using a 15-mm lumen-apposing metal stent. Stent malposition occurred in six and was managed by rescue maneuvers. ERCP was performed in the same session in four patients; the remainder were delayed after a mean of 48 days. Diagnostic endoscopic ultrasound (EUS) was performed in four patients. No severe adverse events occurred; clinical success was 100%. Stents were removed after a mean dwell time of 182 days. Argon plasma coagulation (APC) was used to promote fistula closure in 12 patients. Upper GI series to assess fistula closure was obtained in 11 patients after a mean of 182 days following stent removal. One persistent fistula was identified and closed endoscopically.

CONCLUSIONS

EDGE is an effective modality for performing ERCP in patients with RYGB anatomy and can be performed via gastrogastric or jejunogastric approaches. Persistent fistula is uncommon and can be managed endoscopically. APC may promote fistula closure.

Pancreatic Head Resection Following Roux-en-Y Gastric Bypass: Operative Considerations and Outcomes

PURPOSE

This study aimed to identify optimal management decisions for surgeons preforming pancreatic head resection on patients with altered anatomy due to a previous Roux-en-Y gastric bypass (RYGB).

METHODS

A multi-national (4), multi-center (28) collaborative of 55 pancreatic surgeons who have performed pancreatoduodenectomy or total pancreatectomy following RYGB for obesity (2005-2018) was created. Demographics, operative details, and perioperative outcomes from this cohort were analyzed and compared in a propensity-score matched analysis with a multi-center cohort of 5533 pancreatoduodenectomies without prior RYGB.

RESULTS

Ninety-six patients with a previous RYGB undergoing pancreatic head resection were assembled. Pathologic indications between the RYGB and normal anatomy cohorts did not differ. Propensity score matching of RYGB vs. patients with unaltered anatomy demonstrated no differences in major postoperative outcomes. In total 20 distinct reconstructions were employed (of 37 potential options); the three most frequent reconstructions accounted for 52.1%, and none demonstrated superior outcomes. There were no differences in outcomes observed between original biliopancreatic limb use (66.7%) and those where a secondary Roux limb was created for biliopancreatic reconstruction. Remnant stomachs were removed in 54.7% of cases, with no outcome differences between resected and retained stomachs. Venting gastrostomy tubes were used in 36.2% of retained stomachs without obvious outcome benefits. Jejunostomy tubes were used infrequently (11.7%).

CONCLUSIONS

Pancreatic head resection after RYGB is an infrequently encountered, unique and challenging scenario for any given surgeon. These patients do not appear to suffer higher morbidity than those with unaltered anatomy. Various technical reconstructive options do not appear to confer distinct benefits.

Laparoscopic management of gastric remnant ischemia after laparoscopic distal gastrectomy with Billroth-I anastomosis-A case report

INTRODUCTION

Gastric remnant ischemia after laparoscopic distal gastrectomy (LDG) in gastric cancer patients is a very rare but life-threatening condition, especially when accompanied by a splenic infarction or unplanned splenectomy.

PRESENTATION OF CASE

A 72-year-old male with no comorbid diseases was diagnosed with a well-differentiated adenocarcinoma of the lower stomach and underwent LDG with D2 lymph node dissection. However, a splenic artery injury necessitated a splenectomy intra-operatively, and delta anastomosis was performed based on a clinically viable remnant stomach. During the late post-operative period, the patient developed abdominal pain and showed increased levels of inflammatory biomarkers with hemodynamic stability. Esophagogastroduodenoscopy (EGD) showed necrotic patches over the distal part of the remnant stomach with normal anastomosis and duodenal mucosa. Progression of the necrosis was noted on follow up EGD performed 15 days post-surgery. Total laparoscopic subtotal gastrectomy with Roux-en-Y reconstruction was performed and the patient recovered uneventfully.

DISCUSSION

Careful dissection of the lymph nodes over the major vessels is essential to avoid complications in gastric cancer patients requiring LDG. Moreover, major complications occurring intra-operatively may necessitate changes in the surgical plan, including re-excision of the remnant stomach or conversion to Roux-en-Y reconstruction.

CONCLUSION

Careful evaluation of the clinical findings and close observation with EGD can help detect mucosal demarcation lines and ascertain the perfect timing for intervention in cases with suspected ischemia. Although gastric remnant ischemia requires emergency treatment, laparoscopic management is a feasible option when performed by an expert surgeon.

Laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass in the pediatric population: a MBSAQIP analysis

BACKGROUND

The growing prevalence of childhood obesity has resulted in an increased number of children and adolescents who undergo bariatric surgery. The safety of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) remains controversial in the pediatric population.

OBJECTIVE

To assess the safety of LSG compared with LRYGB in patients aged ≤21 years.

SETTING

A retrospective analysis of the 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

Patients aged ≤21 years who underwent LSG or LRYGB were identified in the 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. A logistic regression model was used to create a 1:1 propensity-score matched cohort adjusting for age, sex, body mass index, and obesity-related co-morbidities. Unmatched and propensity-score matched analyses were performed to compare baseline characteristics and outcome data between LSG and LRYGB procedure groups. Primary outcomes of interest included 30-day major complications, such as death, reoperation, and anastomotic leak.

RESULTS

Of 3571 patients included in our study, 2911 (81.52%) underwent LSG and 660 (18.48%) underwent LRYGB. Patients who underwent LRYGB had an increased body mass index and a higher rate of obesity-related co-morbidities. The LRYGB group had a significantly increased rate of major complications within the first 30 days in both the unmatched cohort (4.55% versus 1.34%, P < .001) and the propensity-score matched cohort (4.57% versus .91%, P < .001).

CONCLUSIONS

LSG and LRYGB are both relatively safe to perform in the pediatric population with acceptable complication rates and low mortality. However, LSG demonstrated a significantly decreased rate of major complications in the first 30 days compared with LRYGB.

An Investigation of Racial Disparities in Weight Loss Outcomes: Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy

OBJECTIVE

The current study aimed to test if racial disparities in weight loss outcomes between African American and Caucasian patients who underwent bariatric surgery were due to pre-surgical BMI differences.

METHODS

Primary data was collected from pre-surgical evaluations conducted at a midwestern hospital. A retrospective chart review was conducted of 136 patients. Patient age and race, type of procedure, and pre- and 1-year post-surgical BMI were collected.

RESULTS

African American patients were less likely to undergo bariatric surgery compared with Caucasian patients. Caucasian patients undergoing Roux-en-Y Gastric Bypass (RYGB) had a greater change in BMI compared with African American patients who underwent RYGB. Significant differences in weight loss outcomes were not found among patients who underwent the sleeve gastrectomy. Race was not related to pre-surgical BMI or procedure type.

CONCLUSION

Despite pre-surgical BMI typically being higher among African American patients, this was not found in the current study. Pre-surgical BMI may not explain the racial disparities in weight loss post-bariatric surgery that are found between African American and Caucasian patients. Future studies should consider psychosocial, environmental, and cultural influences on racial disparities.

Implications of Celiac Disease Among Patients Undergoing Gastric Bypass

INTRODUCTION

Bariatric surgery is generally safe and effective, but co-existing malabsorptive processes may increase the risk of complications or nutritional deficiencies. Bariatric surgery has not been well studied in the setting of pre-existing celiac disease.

MATERIALS AND METHODS

Patients who underwent Roux-en-Y gastric bypass (RYGB) from January 2002 to December 2015 were retrospectively reviewed for either diagnosis of or serum testing for celiac disease. Identified patients were re-reviewed for adherence to American Gastroenterological Association (AGA) diagnostic criteria. Patient demographics, operative data, and post-operative weight loss and nutritional parameters were collected.

RESULTS

Of the > 12,000 patients who underwent bariatric surgery during this study period, there were 342 patients that had abnormal serology or pathology results. Expert review confirmed three patients (0.8%) with celiac disease diagnosed before RYGB procedure. All were female, with an average age of 33 years and a mean BMI of 44.07 kg/m². At the time of surgery, two of the three patients were following a gluten-free diet. At 6 months follow-up, mean % excess weight loss was 76.5%. The patients following a gluten-free diet preoperatively continued post-operatively. No patients were anemic nor had vitamin B12 or iron deficiencies at 12-month follow-up. Two patients had vitamin D insufficiencies and responded to daily oral supplementation.

CONCLUSION

Though many bariatric patients may carry a presumptive diagnosis of celiac disease, a small percentage of these meet AGA diagnostic criteria. RYGB appears safe in this population with comparable weight loss in non-celiac counterparts. Increased attention to vitamin D levels may be warranted post-operatively.

Robotic-Assisted Roux-en-Y Gastric Bypass: Learning Curve Assessment Using Cumulative Sum and Literature Review

Purpose: Robotic-assisted Roux-en-Y gastric bypass (RARYGB) is a procedure that is used with increasing frequency in the United States. Among other bariatric procedures, RARYGB is a good model for the robotic platform because it allows hand-sewn suturing and energy devices application. The aim of this study was to conduct a literature review of robotic approach in RARYGB, its learning curve using the cumulative sum (CUSUM) method, and our experience as Center of Excellence recognized by the American Society for Metabolic and Bariatric Surgery (ASMBS). Methods: A total of 67 patients were included. Results revealed that the learning curve was achieved after case 11. Eighteen studies were included in the pooled analysis. Results: An increase in the operative time was noted at case 46, in which a second phase was identified. A significant difference between these two phases was found only related to previous bariatric surgery. The outcomes of this series were comparable with the ones available in the literature. Conclusions: The robotic platform is increasing its role in complex procedures such as RARYGB. The hand-sewn technique may offer important advantages in terms of shorter learning curve, reduced conversion rate, and lower leakage rate.