Laparoscopic gastric bypass for refractory morbid obesity

Endoscopic Closure of Gastro-gastric Fistula After Gastric Bypass: a Technically Feasible Procedure but Associated with Low Success Rate

BACKGROUND

Gastro-gastric fistulas (GGF) are reported to be as high as 12% after gastric bypass for treatment of morbid obesity. While different endoscopic methods are described, the management traditionally consists of surgical revision with high associated morbidity. The aim of the study was to assess feasibility, safety and success rate of endoscopic closure using an endoscopic suturing device.

METHODS

From January 2016 to March 2018, we reviewed the electronic records of all patients undergoing endoscopic closure of a GGF with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details, and outcome variables were recorded.

RESULTS

A total of six patients (M:F = 5:1) underwent endoscopic fistula closure. Five patients (83.3%) had a prior banded gastric bypass (with subsequent band removal). The median number of prior abdominal surgeries was 3, the mean time from bypass to endoscopic fistula closure was 5 years (range 1.1-10.4). While immediate complete endoscopic fistula closure was possible in 10 of 12 attempts in those six patients (83%), all patients had recurrent (persistent) fistulas at follow-up. After a mean follow-up time of 12 months, 83.3% had further laparoscopic converted to open (n = 2) or laparoscopic (n = 3) revisions with complete fistula closure. One patient is refusing further intervention.

CONCLUSION

Endoscopic gastro-gastric fistula closure with an endoscopic suturing device is feasible and safe. Unfortunately, due to the nature of gastro-gastric fistulas, permanent successful closure is rare. Therefore, the approach should be reserved for patients in whom a laparoscopic or open surgical attempt is impossible due to prior abdominal revisions.

Mid-term results of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in adolescent patients

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m2. The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81%) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.

Twelve year experience of laparoscopic gastric plication in morbid obesity: development of the technique and patient outcomes

BACKGROUND

Laparoscopic Gastric Plication (LGP) is a new restrictive bariatric surgery, previously introduced by the author. The aim of this study is to explain the modifications and to present the 12-year experience, regarding early and long term results, complications and cost.

METHODS

We used LGP for morbid obesity during the past 12 years. Anterior plication (10 cases), one-row bilateral plication while right gastroepiploic artery included (42 cases), and excluded from the plication (104 cases) and two-row plication (644 cases). The gastric greater curvature was plicated using 2/0 prolen from fundus at the level of diaphragm preserving the His angle to just proximal to the pylorus. The anatomic and functional volume of stomach was 50cc and 25cc respectively in two-row method. Ordered postop visits also included evaluation of weight loss, complications, change of diet and control of exercise.

RESULTS

LGP was performed in 800 cases (mean age: 27.5, range: 12 to 65 years, nine under 18). Female to male ratio was 81% to 19% and average BMI was 42.1 (35-59). The mean excess weight loss (EWL) was 70% (40% to 100%) after 24 months and 55% (28% to 100%) after 5 years following surgery. 134 cases (16.7%) did not completed long term follow-up. The average time of follow up was 5 years (1 month to 12 years). 5.5% and 31% of cases complained from weight regain respectively during 4 and 12 years after LGP. The mean time of operation was 72 (49-152) minutes and average hospitalization time was 72 hours (24 hours to 45 days). The cost of operation was 2000 $ less than gastric banding or sleeve and 2500 $ less than gastric bypass. Eight patients out of 800 cases (1%) required reoperation due to complications like: micro perforation, obstruction and vomiting following adhesion of His angle. Other complications included hepatitis pneumonia, self-limiting intra-abdominal bleeding and hypocalcaemia.

CONCLUSION

The percentage of EWL in this technique is comparable to other restrictive methods. The technique is safe with 1.6% complication (1% reoperated), and 31% regain during 12 years. The cost of operation is less than the other methods.

Outcomes of bariatric surgery in patients >70 years old

BACKGROUND

The aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States.

METHODS

A retrospective review was performed of prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities.

RESULTS

Of 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m(2), respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m(2), respectively. The median length of follow-up was 12 months (range 1-66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively.

CONCLUSION

Bariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.

Endoscopic repair of gastrogastric fistula after Roux-en-Y gastric bypass: a less-invasive approach

BACKGROUND

Gastrogastric fistulas (GGFs) are a well-known complication of Roux-en-Y gastric bypass. Surgical repair of such fistulas is technically difficult, with significant associated morbidity. The aim of the present study was to evaluate the efficacy of endoscopic GGF closure at a university hospital in the United States.

METHODS

Patients with Roux-en-Y gastric bypass and confirmed GGFs on esophagogastroduodenoscopy or barium study. Endoscopic repair was performed with the EndoCinch suturing system (group 1) or clips (group 2). All patients were followed up in the outpatient clinic or interviewed by telephone at 1, 6, and 18 months after the procedure, then as indicated by symptoms.

RESULTS

A total of 95 patients were included in the present series (group 1, n = 71, 75%; group 2, n = 24, 25%). The mean GGF size was significantly larger in group 1 than in group 2 (14.5 +/- 8.7 versus 7.7 +/- 6, P = .01). An average of 2.2 sutures or 3 clips (range 2-7) was used. Complete initial GGF closure was achieved in 90 patients (95%), with reopening in 59 (65%) an average of 177 +/- 202 days. The average follow-up was 395 +/- 49 days, with 22 patients lost to follow-up. Two significant complications were reported (bleeding and an esophageal tear). None of the GGFs with an initial size >20 mm remained closed during the follow-up period compared with 10 (32%) of the 31 fistulas <or=10 mm in diameter remained closed.

CONCLUSION

Peroral endoscopic repair of postbariatric GGFs is technically feasible and safe but with limited durability. The fistula size predicted for long-term outcomes, with the best results seen in fistulas <or=10 mm in diameter.

Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass surgery

PURPOSE

The purpose of this study was to review the etiology and computed tomography (CT) findings of small-bowel obstruction (SBO) in patients who have undergone bariatric laparoscopic Roux-en-Y gastric bypass (LGBP) surgery.

MATERIALS AND METHODS

Prospectively entered data from a surgical database of 835 consecutive patients who underwent antecolic-antegastric LGBP for morbid obesity from June 1999 to April 2005 in a single institution were retrospectively reviewed. A total of 42 cases of bowel obstruction were observed in 41 patients. Surgical proof was available in 38 cases, and 4 cases had characteristic imaging features and/or clinical follow-up. Seventeen CT scans were reviewed to determine cause and level of obstruction, and this was correlated with surgical findings and clinical follow-up.

RESULTS

Internal hernia was the most common (13 cases) and also the most frequently missed etiology of SBO on CT scans, with the diagnosis being made prospectively in only 2 of 6 cases, in which CT was done. Adhesions, ventral hernia, postoperative ileus, and jejunojejunal (JJ) anastomotic strictures, in that order, were the other commonly observed etiologies for SBO, with 11, 7, 5, and 4 cases, respectively. Some causes of SBO post-LGBP (JJ anastomotic stricture and postoperative ileus) developed relatively early, whereas others (internal hernia) tended to develop later or had a bimodal distribution (adhesions and ventral hernia). Fifteen (36%) of 42 cases had SBO at or near the level of jejunojejunostomy site; causes included internal hernia (5 cases), adhesions/kinking of small bowel (5 cases), JJ anastomotic stricture (4 cases), and JJ intussusception (1 case).

CONCLUSION

The time interval between LGBP and development of SBO might provide a useful clinical clue to its etiology. The JJ level is an important location for SBO post-LGBP because of a variety of causes, and special attention must be paid to this site at imaging of post-LGBP patients.

Laparoscopic total gastric vertical plication in morbid obesity

BACKGROUND

The aim of this study was to introduce a new technique, total gastric vertical plication (TGVP), as a restrictive operation. It has the same result of weight loss as others with minimal risk of complication and very low cost, especially in developing countries.

METHODS

This technique was used by one surgeon in private hospitals during 3 years in Tehran, Iran. Patients were placed in the supine position with a 30-degree reverse Trendelenburg position. Trocars were inserted based on an ergonomic assessment (three 5 mm and one 10 mm). After the release of the greater curvature, continuous sutures were used with 00 nylon from the fondus to 3 cm of the pylorus. A vertical plication was performed in one or two layers. Distance between the stitch and lesser curvature was 2 cm in the anterior and posterior and between each stitch, all of them getting extra mucosal (far away from acid effect) owing to mild tension on the sutures that cut mucosa and put on a submucosa layer.

RESULTS

TGVP was performed in 100 cases (mean age, 32; standard error of the mean = 2.1); mostly female (F/M = 76/24) and with average body mass index of 47 (36-58). The mean weight loss in our patients was 21.4% of excessive weight loss (EWL) 1 month after the operation, 54% after 6 months (72 cases), 61% after 12 months (56 cases), 60% after 24 months (50 cases), and 57% after 36 months (11 cases). The average time of follow-up was 18 months. The mean time of operation was 98 (70-152) minutes and all of the patients were discharged from the hospital after an average of 1.3 days (range, 1-4). The main postoperative complications were permanent vomiting, intracapsular liver hematoma, hypocalcemia at early postoperative period, hepatitis, leakage at the suture line, and acute gastric perforation. The volume of the stomach in this condition was 100 cc, but just one half of it was effective. If more than 50 cc was used, a painful condition would occur.

CONCLUSIONS

The percentage of EWL in this technique is comparable to other restrictive methods, but EWL appears more rapidly. Early postoperative complications of this method are minimal, without any important late complications. This technique needs more expertise and is more time consuming. A long-term follow-up is advised.

Female reproductive issues following bariatric surgery

One in 3 adult American women is obese. Almost half of the approximately 100,000 bariatric surgeries performed in 2004 were on reproductive-aged women. Anatomic and physiologic changes resulting from such surgery may have significant clinical implications for preconception, pregnancy, and postpartum care. This review summarizes these issues and the available related literature, and offers guidelines for care of these patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that bariatric surgery has many anatomic and physiologic changes that potentially will affect future pregnancies, and state that attention to these physiologic changes and attention to potential nutritional deficiencies significantly improves the chances of a good pregnancy outcome.

Safety and outcomes of laparoscopic gastric bypass surgery in patients 60 years of age and older

BACKGROUND

Many surgeons are hesitant to offer bariatric surgery to patients >60 years of age because of concern of the considerably greater perioperative risk and less weight-control efficacy. We hypothesized that laparoscopic Roux-en-Y gastric bypass (LRYGB) can be performed in this patient population with acceptable morbidity and can achieve effective weight control.

METHODS

A retrospective review was performed of patients >60 years of age who had undergone LRYGB at the Bariatric Institute at Cleveland Clinic Florida from 2001 to 2004. The data assessed included age, gender, preoperative and postoperative weight and body mass index (BMI), and postoperative complications.

RESULTS

A total of 92 patients >60 years who had undergone LRYGB were reviewed in this study. The mean preoperative weight and BMI was 136.6 kg and 48.4 kg/m(2), respectively. The mean postoperative weight and BMI was 100.3 kg and 35.9 kg/m(2), respectively. The mean percentage of excess weight loss was 53.85%. The early complications were an anastomotic leak in 2 patients (2.2%), intraluminal hemorrhage in 1 patient (1.1%), pulmonary embolus in 1 patient (1.1%), pneumonia in 1 patient (1.1%), and atrial fibrillation in 1 patient (1.1%). The late complications included stenosis at the gastrojejunostomy in 8 patients (8.6%), marginal ulceration in 3 (3.2%), small bowel obstruction in 1 (1.1%), internal hernia in 1 (1.1%), and abdominal wall hernia in 1. No mortality occurred.

CONCLUSION

LRYGB can be performed safely and can achieve effective weight control in patients >60 years of age.

Ultradian ghrelin pulsatility is disrupted in morbidly obese subjects after weight loss induced by malabsorptive bariatric surgery

BACKGROUND

Suppression of ghrelin production after Roux-en-Y gastric bypass that suggested its contribution to appetite reduction has been reported.

OBJECTIVE

Because biliopancreatic diversion (BPD) does not affect appetite, we compared ghrelin production and 24-h pulsatility between healthy control subjects and obese subjects before and after BPD.

DESIGN

A computerized algorithm identified peak heights, clearance rate, and peak frequency of ghrelin over 24 h. Twenty-four-hour energy expenditure was measured in the calorimetric chamber, and energy intakes were computed. Insulin sensitivity was measured with a euglycemic-hyperinsulinemic clamp.

RESULTS

Mean (+/-SD) 24-h plasma ghrelin concentrations were significantly (P < 0.0001) higher in control than in obese subjects (338.17 +/- 22.09 and 164.47 +/- 29.19 microg/L, respectively), but they increased to 204.64 +/- 28.51 microg/L in the obese subjects after BPD (P < 0.01). The pulsatility index was 0.098 +/- 0.016 and 0.041 +/- 0.014 microg . L(-1) . min(-1) in control and obese subjects, respectively (P < 0.01), and decreased to 0.025 +/- 0.007 microg . l(-1) . min(-1) after BPD (P < 0.05). Energy intakes before and after BFP did not differ significantly. Although metabolizable energy after BPD was 40% of the energy intake, that (per kg fat-free mass) after BPD did not different significantly from that before BPD.

CONCLUSIONS

Weight loss induced by malabsorptive bariatric surgery is associated with greater ghrelin concentrations, which, however, remain consistently lower than those in control subjects, whereas ghrelin pulsatility is subverted. Higher ghrelin concentrations may contribute to the high calorie intakes observed in post-BPD subjects. The lack of normal pulsatility may explain the new impulse of these subjects to eat very frequently.

Endoscopic issues in the post-gastric bypass patient

Obesity in the United States poses a tremendous health risk to approximately one third of the population. As this epidemic grows, the number of bariatric surgeries performed will also increase. Although obesity itself is not gender specific, 85% of bariatric surgeries are performed in women. This article reviews some of the commonly performed weight-reduction surgeries and their associated complications. Particular emphasis is placed on the diagnostic and therapeutic implications of endoscopy in this population.

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure.

METHODS

We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery.

RESULTS

The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically.

CONCLUSION

Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.