Bariatric Surgery: Past and Present

An insidious internal hernia 30 years after jejunoileal bypass: a case report

Jejunoileal bypass (JIB) was an early bariatric procedure that involved bypassing most of the small bowel resulting in malabsorption and weight loss. Due to serious complications associated with the procedure, JIB was largely discontinued by the mid-1980s. We report the case of a 77-year-old woman with a history of JIB 31 years earlier. In 2022, she was hospitalized for acute abdominal pain. A computed tomography (CT) scan revealed a suspicion of internal hernia (IH) with a typical swirl sign. Due to the quick relief of symptoms an emergency surgery was not considered at the time. Nevertheless, a subsequent operation revealed a large mesenteric defect, adhesions and 100 cm of effective small bowel left. Although the procedure is no longer performed, some patients with JIB are still alive and develop late complications. To our knowledge, this is the first case report describing an IH in a patient who has undergone JIB.

Changes in Urine Composition and Risk of Kidney Stone Disease Following Bariatric Surgery: A Systematic Review over Last 2 Decades

PURPOSE OF REVIEW

The association of kidney stone disease (KSD) and gastrointestinal (GI) surgery has been well established. With a rising obesity crisis, we wanted to see the correlation of urinary composition in patients undergoing bariatric surgery and their risk of KSD. The objective of this paper is to perform a systematic review and meta-analysis of literature to evaluate the changes in urinary composition and risk of KSD following bariatric surgery.

RECENT FINDINGS

A total of seven studies (2498 patients) underwent bariatric surgery with a mean age of 46.7 years and a male:female ratio of 1:3. The most popular bariatric surgery was the Roux-en-Y procedure. Meta-analysis of the studies showed that significant decrease in urinary calcium, citrate, and urate, and increase in urinary oxalate. There was also a nonsignificant volume reduction in the post-operative cohort. The decrease in urinary citrate and increase in urinary oxalate are both predisposing factors of stone formation. There is strong evidence that bariatric surgery results in significant changes in urine composition in keeping with the increased risk of developing KSD. This identifies useful therapeutic targets in the prophylactic management of patients who have undergone bariatric surgery.

Improving vitamin D status in bariatric surgery subjects with monthly high-dose ergocalciferol

Background: Vitamin D insufficiency is common before and after bariatric surgery. Optimal supplementation to treat vitamin D insufficiency is not clearly defined. Objective: Determine if serum 25 (OH) D levels improve by the consumption of an additional monthly ergocalciferol supplement by subjects after bariatric surgery. Study design: Thirty-two subjects were randomly divided to receive an additional 100,000 IUs of ergocalciferol monthly after bariatric surgery (n=10) or standard level vitamin D supplement after bariatric surgery (n=22). Serum 25 (OH) D, calcium, and hemoglobin A1c levels were measured preoperatively and one year after bariatric surgery. Results: Mean changes in BMI at 1-year post-operation was -18.12±6.46 kg/m² in the control group versus -18.84±4.7 kg/m²; p=0.638 in the vitamin D group. One year after bariatric surgery, the mean changes from baseline in vitamin D levels were 2.69±9.4 and 12.4±17.0 ng/mL in control and intervention groups, respectively. The treated group showed a marginally higher mean increase in Vitamin D than the control group, p=0.059. Other mean changes at 1-year post-surgery that were not significantly different include calcium -0.264±0.45 and -0.21±0.509 mg/dl in control and intervention groups, respectively and Hgb A1c -1.0±1.21 and -0.95±0.071% in control and intervention groups, respectively. Conclusion: This study showed 100,000 IUs ergocalciferol once a month is a safe and effective treatment for vitamin D insufficiency in most patients having bariatric surgery.

Endoscopic Dilation of Post-Sleeve Gastrectomy Stenosis: Long-Term Efficacy and Safety Results

INTRODUCTION

Post-sleeve gastrectomy (SG) stenoses occur in about 5% of cases. Hydrostatic dilation (HD) and pneumatic dilation (PD) have been proposed as treatments, but efficacy data remain scarce. Objective is to describe long-term efficacy and safety of HD and PD.

METHODS

This retrospective study in a referral endoscopy center included patients with symptomatic post-SG stenosis treated with endoscopic balloon dilation (EBD). Stenosis was defined as "organic" if luminal narrowing was evident, "functional" for a deformation, or "combined." Endoscopic treatment consisted of ≥ 1 HD (15-20 mm) and/or ≥ 1 PD (30-35 mm). Initial success was defined as improvement of stenosis-related symptoms at 1 month and long-term success as persistence of improvement at last follow-up.

RESULTS

Forty-four patients (73% women; mean age 45.5 ± 11 years; mean follow-up 26 ± 23 months) underwent EBD between 2013 and 2019. HD and PD were used in 15 (34%) and 29 (66%) patients, respectively, (mean dilation number: 1.8 ± 1.1). Post-SG stenoses were considered organic in 10 (23%), functional in 21 (48%), and combined in 13 (29%) patients. Initial success was achieved in 42 (96%) patients, while 35 (80%) patients had no symptom recurrence at last follow-up. Perforation occurred in one patient. HD was more frequently used in organic stenoses (8/10), while PD in functional and combined stenoses (18/21 and 9/13, respectively; p < 0.001). Rates of success did not differ by type of stenosis.

CONCLUSION

Endoscopic dilation is an effective treatment for post-SG stenoses, providing long-term symptom relief. PD should be preferred in cases of functional stenoses, and HD used for organic stenoses.

Endoscopic gastrointestinal anastomosis: a review of established techniques

Technologic advancements in the field of therapeutic endoscopy have led to the development of minimally invasive techniques to create GI anastomosis without requiring surgery. Examples of the potential clinical applications include bypassing malignant and benign gastric outlet obstruction, providing access to the pancreatobiliary tree in those who have undergone Roux-en-Y gastric bypass, and relieving pancreatobiliary symptoms in afferent loop syndrome. Endoscopic GI anastomosis is less invasive and less expensive than surgical approaches, result in improved outcomes, and therefore are more appealing to patients and providers. The aim of this review is to present the evolution of luminal endoscopic gastroenteric and enteroenteric anastomosis dating back to the first compression devices and to describe the clinical techniques being used today, such as magnets, natural orifice transluminal endoscopic surgery, and EUS-guided techniques. Through continued innovation, endoscopic interventions will rise to the forefront of the therapeutic arsenal available for patients requiring GI anastomosis.

Bariatric Surgery Outcomes in Appalachia Influenced by Surgery Type, Diabetes, and Depression

Background

Most effective treatment for morbid obesity and its comorbidities is bariatric surgery. However, research is limited on weight loss and associated outcomes among patients in Appalachia. The objective of this study was to examine demographic and comorbidity influence on surgical outcomes of this population including age, sex, race, state of residence, education, marital status, body mass index (BMI kg/m²), excess body weight (EBW), percent excess weight loss (%EWL), blood pressure, diagnosed depression, diagnosed type 2 diabetes (T2D), Beck Depression Inventory-II (BDI-II), and laboratory values (i.e., hemoglobin A1c).

Methods

A retrospective electronic medical record (EMR) data extraction was performed on N = 582 patients receiving bariatric surgery (laparoscopic Roux-en-Y gastric bypass [RYGB] and laparoscopic sleeve gastrectomy [SG]) between 10/2013 and 2/2017.

Results

Patient population was 92.5% Caucasian, 79.3% female, 62.8% married, 45 ± 11.1 years, 75.8% received RYGB, and 24.2% received SG. Average %EWL from baseline to 1-year follow-up was 68.5 ± 18.4% (n = 224). In final descriptive models, surgery type, diagnosed T2D, HbA1c, and depressive symptoms were significant covariates associated with lower %EWL.

Conclusions

Findings suggest patients completing surgery within an Appalachian region have successful surgical outcomes at 1-year post-surgery, as indicated by significant reductions of > 50% EWL, regardless of other covariates. Results suggest that bariatric programs should consider paying special consideration to patients with T2D or depressive symptoms to improve outcomes. Results have potential to inform future prospective studies and aid in guiding specific interventions tailored to address needs of this unique population.

Managing Bariatric Patients in Dentistry

Obesity is a growing issue across the world, presenting a range of challenges to society. Management of obese or bariatric patients in the dental environment has become more commonplace. This article considers an overview of obesity, reviews its dental impact and offers some solutions to minimising those challenges in the dental setting.

Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model.

MATERIAL AND METHODS

A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed.

RESULTS

We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis.

CONCLUSION

Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.

Gastrojejunal Anastomosis Exclusively Using the "NOTES" Technique in Live Pigs: A Feasibility and Reliability Study

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES.

METHODS

It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery.

RESULTS

The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers.

CONCLUSION

Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.

Crohn's disease after gastric bypass surgery

Bariatric surgery for the treatment of severe obesity has increased dramatically in recent years in the USA and parts of Western Europe. The most commonly used technique is the Roux-en Y gastric bypass (RYGBP). Several nutritional and gastrointestinal complications after bariatric surgery have been described during the last 10 years. The authors present two patients with diarrhoea and malnutrition; one after RYGBP and the other after jejunoileal bypass surgery. These patients were subsequently diagnosed with Crohn's disease.

From longitudinal gastric resection to sleeve gastrectomy--revival of a previously established surgical procedure

INTRODUCTION

Sleeve gastrectomy is becoming increasingly popular within bariatric surgery. Initially introduced as a component of complex interventions and later as part of a two-stage operation in high-risk patients, the procedure is now more common as one-stage operation and subject of avid scientific discussion. However, the concept of longitudinal gastric resection is not new. The procedure was already established in ulcer surgery but soon faded into insignificance. This article aims to trace the historical development of resection of the greater curvature with particular reference to its origin in ulcer and bariatric surgery. The contribution of ulcer surgery to modern sleeve gastrectomy is highlighted. Furthermore, the current value of sleeve gastrectomy within the spectrum of bariatric surgical procedures will be discussed. Relevant medical literature from PubMed to April 2010 was reviewed.

DISCUSSION

Besides bariatric surgery modern sleeve gastrectomy has one more so far largely neglected origin: segmental and later longitudinal gastric resection used in ulcer surgery. Experience and achievements from ulcer surgery simplified and facilitated development of sleeve gastrectomy which is not the desired universal procedure for bariatric surgery but certainly an attractive treatment option. It should be performed in a more standardized manner and with due regard to future long-term results.

Factors in selecting the optimal bariatric procedure for a specific patient and parameters by which to measure appropriate response to surgery

Bariatric operations are increasingly being used to induce weight loss and ameliorate or cure most of the morbidities that accompany obesity. These procedures not only produce substantial weight loss (>50% body weight), but they cure or ameliorate the comorbidities (diabetes type 2, hypertension, sleep apnea, hyperlipidemia) in the vast majority of patients. These procedures can usually be performed laparoscopically with a mortality of less than 0.5% and a hospital stay of 1 to 3 days. Presently they are the only effective treatment for weight loss in the extremely obese patient (body mass index >/= 35).

Contraceptive use among women with a history of bariatric surgery: a systematic review

BACKGROUND

Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years.

STUDY DESIGN

We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery.

RESULTS

From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon.

CONCLUSIONS

Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified.

Conversion to gastric bypass in patients with unsuccessful weight loss after gastric banding may depend on mental quality of life

BACKGROUND

A low quality of life has been regarded a cue to action. Some patients with unsuccessful weight loss after laparoscopic adjustable gastric banding (LAGB) undergo a conversion of gastric banding to gastric by-pass. This study examines whether patients who did or did not undergo conversion to gastric bypass differed in quality of life before and after gastric banding.

METHODS

Of 34 patients with unsuccessful weight loss after gastric banding (excess body mass index loss < 25%), 14 had a conversion to gastric bypass 2 years or more after gastric banding. All patients completed the RAND-36 quality of life questionnaire before gastric banding. After gastric banding, 24 patients (70.6%) filled out the RAND-36 at 6, 12, and 24 months.

RESULTS

Pre-banding and postbanding mental quality of life was lower in the conversion compared to the non-conversion group.

CONCLUSION

Our results suggest that a relatively stable lower mental quality of life is a signal for further intervention. The bariatric team and patients should be aware that mental health may play a role in the decision for conversion to gastric bypass. The possible mechanisms underlying this finding, and limitations of the study are discussed.

Impact of obesity on female fertility and fertility treatment

Obesity and overweight are common conditions that have consequences not only on general health but also to a great extent on reproductive health. There is a high prevalence of obese women in the infertile population and numerous studies have highlighted the link between obesity and infertility. Obesity contributes to anovulation and menstrual irregularities, reduced conception rate and a reduced response to fertility treatment. It also increases miscarriage and contributes to maternal and perinatal complication. Reduction of obesity, particularly abdominal obesity, is associated with improvements in reproductive functions; hence, treatment of obesity itself should be the initial aim in obese infertile women before embarking on ovulation-induction drugs or assisted reproductive techniques. While various strategies for weight reduction, including diet, exercise, pharmacological and surgical intervention exist, lifestyle modification continues to be of paramount importance.

Conversion of intestinal bypass to Roux-en-Y gastric bypass: a case report and brief review

Intestinal bypass procedures for the treatment of morbid obesity have been largely replaced by Roux-en-Y gastric bypass procedures. The main reason for this change over the past 40 years stems from the myriad of negative nutritional and physiologic repercussions of intestinal bypass procedures. We present a case of a patient with severely atrophied small bowel and the novel method used for the conversion of the intestinal bypass procedure to Roux-en-Y gastric bypass. Additionally, we present a brief review of jejunoileal bypass.

Obesity, bariatric surgery, and iron deficiency: true, true, true and related

Morbid obesity is a health problem that has been shown to be refractory to diet, exercise, and medical treatment. Surgeries designed to promote weight loss, termed bariatric surgery and typically involving a gastric bypass procedure, have recently been implemented to treat obesity with high success rates. However, long-term sequelae can result in micronutrient deficiencies. This review will focus on iron deficiency and its association with obesity and bariatric surgery. Iron deficiency develops after gastric bypass for several reasons including intolerance for red meat, diminished gastric acid secretion, and exclusion of the duodenum from the alimentary tract. Menstruating women, pregnant women, and adolescents may be particularly predisposed toward developing iron deficiency and microcytic anemias after bypass surgery. Preoperative assessment of patients should include a complete hematological work-up, including measurement of iron stores. Postoperatively, oral iron prophylaxis and vitamin C in addition to a multivitamin should be prescribed for bypass patients, especially for vulnerable populations. Once iron deficiency has developed, it may prove refractory to oral treatment, and require parenteral iron, blood transfusions, or surgical interventions. Bariatric surgery patients require lifelong follow-up of hematological and iron parameters since iron deficiency and anemia may develop years after surgery.

Hematological manifestations of copper deficiency: a retrospective review

Copper deficiency is an established cause of hematological abnormalities but is frequently misdiagnosed. Copper deficiency can present as a combination of hematological and neurological abnormalities and it may masquerade as a myelodysplastic syndrome. We reviewed the records of patients with hypocupremia and hematologic abnormalities identified between 1970 and 2005. Patients with hypocupremia unrelated to copper deficiency (e.g. Wilson's disease) were excluded. Forty patients with copper deficiency and hematological abnormalities were identified. Ten patients (25%) had undergone bariatric (weight reduction) surgery and an additional 14 patients (35%) had undergone surgery on the gastrointestinal tract, most commonly gastric resection. In 12 cases, no cause for copper deficiency was identified. Anemia and neutropenia were the most common hematologic abnormalities identified and the majority of the patients also had neurologic findings, most commonly due to myeloneuropathy. Abnormalities observed on bone marrow examination including vacuoles in myeloid precursors, iron-containing plasma cells, a decrease in granulocyte precursors and ring sideroblasts may be valuable clues to the diagnosis. Copper deficiency is an uncommon but very treatable cause of hematologic abnormalities.

Análise radiológica das alterações gastrintestinais após cirurgia de Fobi-Capella

OBJETIVO: Estudar os achados radiológicos encontrados na seriografia digestiva alta no pós-operatório tardio de cirurgia de Fobi-Capella. MATERIAIS E MÉTODOS: Estudo radiológico de 41 pacientes realizado seis a nove meses após a cirurgia de Fobi-Capella. RESULTADOS: As alterações encontradas foram hérnia hiatal (17%), refluxo gastroesofágico (19,5%) e deslizamento do anel (4,8%). Os achados menos freqüentes foram fístula enterocutânea (2,4%), estenose da anastomose gastrojejunal (2,4%), bezoar (2,4%) e não-visualização do anel em decorrência da sua retirada por intolerância (2,4%). As alterações anatômicas da cirurgia foram claramente demonstradas. CONCLUSÃO: O estudo foi capaz de demonstrar as alterações anatômicas e as complicações da cirurgia de Fobi-Capella.

Gastric Slippage as an Emergency: Diagnosis and Management

Laparoscopic adjustable gastric banding (LAGB) is an increasingly common procedure for morbid obesity. The most prevalent complication following LAGB is band slippage leading to gastric prolapse. These cases often present to the emergency department where surgeons need to appropriately diagnose and stabilize the patient, prior to any surgical intervention. It is imperative that surgeons at all levels of training implement an organized, effective acute management plan to reduce the morbidity and mortality associated with this life-threatening condition. This report highlights the case of a gastric banding patient who presented to an emergency department >1 year after a LAGB operation had been performed, with dysphagia. The diagnosis of gastric prolapse can be overlooked, with potentially serious consequences.