Bowel obstruction rates in antecolic/antegastric versus retrocolic/retrogastric Roux limb gastric bypass: a meta-analysis.

BACKGROUND: Previous literature is varied with regard to rates of bowel obstruction after laparoscopic Roux-en-Y gastric bypass (LRYGB). Internal herniation through mesenteric defects is a common cause of bowel obstructions. There are advantages and disadvantages to routing the Roux limb via a retrocolic/retrogastric (RC/RG) versus an antecolic/antegastric (AC/AG) position. OBJECTIVE: To review the literature comparing obstruction rates in RYGB using the antecolic versus retrocolic approach. SETTING: Community-based integrated multispecialty health system with a teaching hospital serving 19 counties over a 3-state region. METHODS: A literature search for articles published from 1994-2013 was completed. Articles were included if they reported an n>25, Roux limb route, obstruction rate by route, and follow-up duration. Statistical analysis included χ(2) test by patient number. RESULTS: The initial search identified 241 articles; 8 met inclusion criteria. There were 4805 patients in the AC/AG group, and 2238 in the RC/RG group. Follow-up ranged from 0 to 68 months. A linear stapled technique was reported in 4231 (88%) patients in the AC/AG group and 1541 (69%) of RC/RG group. Handsewn closure of mesenteric defects was reported in 2152 (45%) patients in the AC/AG group and 1012 (45%) patients in the RC/RG group. Bowel obstructions occurred in 68 (1.4%) patients in the AC/AG group and 117 (5.2%) patients in the RC/RG group (P<.001). Internal hernias were reported in 65 (1.3%) patients in the AC/AG group and 52 (2.3%) patients in the RC/RG group (P<.001). Two mortalities were reported in the AC/AG group. CONCLUSIONS: Increased rates of bowel obstruction and internal hernia were observed in the RC/RG group compared with the AC/AG group. A prospective, randomized trial would be necessary to definitively determine the impact of Roux limb position and routine closure of mesenteric defects on bowel obstruction rates after gastric bypass.

Complications of laparoscopic Roux-en-Y gastric bypass.

Despite the well-documented safety of laparoscopic RYGB, several short-term and long-term complications, with varying degrees of morbidity and mortality risk, are known to occur. Bariatric surgeons, all too familiar with these complications, should be knowledgeable in risk-reduction strategies to minimize the incidence of complication occurrence and recurrence. Bariatric and nonbariatric surgeons who evaluate and treat abdominal pain should be familiar with these complications to facilitate early recognition and intervention, thereby minimizing the associated morbidity and mortality.

BAROS results in 700 patients after laparoscopic Roux-en-Y gastric bypass with subset analysis of age, gender, and initial body mass index.

BACKGROUND: The Bariatric Analysis and Reporting Outcome System (BAROS) uses a point scale (maximal score of 9) to evaluate weight loss, complications, improvement in medical conditions, and quality of life among postoperative bariatric patients. The BAROS was originally developed to address the need for a standardized method of reporting open gastric bypass outcomes and has been shown to be both valid and reliable. BAROS scores >7 are considered "excellent." Our objective was to assess the overall BAROS scores in patients undergoing laparoscopic Roux-en-Y gastric bypass at each postoperative follow-up interval and to examine the effect of age and gender on BAROS scores. METHODS: A total of 700 patients who had undergone LRYGB were asked to complete a BAROS questionnaire at their postoperative visits. The BAROS scores were recorded in a prospective database. The patients were stratified by their initial age and body mass index. The statistical analysis included analysis of variance. P <.05 was considered significant. RESULTS: The mean BAROS score peaked at 7.29 at the 18-month appointment. More than one half of the patients presenting for follow-up visits at 12, 18, 24, and 36 months had BAROS scores in the "excellent" range. Age stratification (20-29, 30-39, 40-49, and ≥ 50 years) resulted in significant differences at 3, 6, 9, 12, and 18 months postoperatively. When stratified by the initial body mass index, differences were seen at 3 weeks and 3, 6, 9, and 12 months postoperatively. CONCLUSION: Patients with a lower initial body mass index had greater BAROS scores at many of the follow-up intervals. Laparoscopic Roux-en-Y gastric bypass effectively improved the overall health and quality of life of patients.

Natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery.

BACKGROUND: Patients satisfying the National Institutes of Health criteria and deemed appropriate candidates often do not undergo bariatric surgery for insurance-related reasons. Our objective was to explore the natural history of these patients compared with that of those who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: The medical records of the patients evaluated for LRYGB from 2001 to 2007 were retrospectively reviewed. The presence of co-morbidities was assessed at the initial evaluation and within a 3-year follow-up period for patients who had undergone LRYGB and those denied surgery. The statistical analysis included chi-square tests. RESULTS: A total of 189 patients were in the denied cohort and 587 in the LRYGB cohort. The age, gender, and body mass index were similar between the 2 cohorts at the initial evaluation. The percentage of patients with a diagnosis of a co-morbidity in the denied and LRYGB cohorts at the initial evaluation was 20% and 25% with diabetes mellitus, 51% and 43% with hypertension, 20% and 22% with obstructive sleep apnea, 34% and 24% with lipid disorders, and 62% and 49% with gastroesophageal reflux disease, respectively. The body mass index at the initial evaluation and during follow-up was 47.3 and 46.8 kg/m(2) in the denied cohort (n = 165, P = .236) and 48.5 and 30.5 kg/m(2) in the LRYGB cohort (n = 544, P <.001), respectively. During the follow-up period, a greater incidence of new-onset diabetes (P <.001), hypertension (P <.001), obstructive sleep apnea (P <.001), gastroesophageal reflux disease (P <.001), and lipid disorders (P <.001) was observed in the denied cohort. CONCLUSION: Patients denied LRYGB had a greater incidence of new co-morbidities diagnosed within a short follow-up period, without a significant change in their body mass index.

Distinctive presentation of a diaphragmatic hernia 15 years after a traumatic insult.

Diaphragmatic hernias are well-known sequelae of abdominal and chest wall trauma. However, they may go undiagnosed in the acute setting but present later due to gastrointestinal or respiratory complications. A distinctive presentation of a diaphragmatic hernia 15 years after a traumatic insult is herein described. Management strategies are also discussed.