Stomach Intestinal Pylorus-Sparing Surgery for Morbid Obesity.

BACKGROUND AND OBJECTIVE: The Roux-en-Y duodenal switch (RYDS) is one of the most efficient forms of bariatric surgery. However, diarrhea, malnutrition, ulcers, and internal hernias have hampered its widespread adoption. The stomach intestinal pylorus-sparing (SIPS) procedure was developed to alleviate these sequelae while retaining the same weight loss as the RYDS. In this study, we report our midterm experience with this novel technique. METHODS: Retrospective analysis was performed on data from 225 patients who underwent a primary SIPS procedure by 2 surgeons at a single center from October 2013 through December 2016. RESULTS: Two hundred twenty-five patients were identified for analysis. The mean preoperative body mass index (BMI) was 52.4 ± 9.1 kg/m2. Forty-eight patients were beyond 2 years after surgery, with data available for 30 patients (62.5% follow-up). Three patients were lost to follow-up. At 2 years, the patients had an average change in BMI of 26.6 U (kg/m2) with an average of 88.7% of excess weight loss. Three deaths were related to the surgery. The most common short-term complication was a leak (2.2%), whereas the most common long-term complication was diarrhea (2.2%). CONCLUSION: In conclusion, SIPS surgery is a safe procedure with favorable weight loss outcomes at 2 years.

Randomized double-blinded trial of laparoscopic gastric imbrication v laparoscopic sleeve gastrectomy at a single Indian institution.

BACKGROUND: Currently, there is a debate whether the laparoscopic gastric imbrication (LGI) offers similar weight loss when compared to the laparoscopic sleeve gastrectomy (LSG). On the surface, they seem to offer similar-sized stomachs after the procedures are performed. We chose to perform a randomized double-blinded trial to see if similar-sized pouches result in similar types of weight loss. Our belief was that sleeve gastrectomy would offer at least a 10% better weight loss over a 3-year period. METHODS: Thirty patients were randomized to one of two arms. The patients and the third party administrator following the patients were blinded as to which procedure was chosen. The surgeon had full knowledge of the patients' surgery throughout the treatment. The decision of which arm to place them was made by a single employee of the third party administrator and not shared with the employees following the patients. Patients were then followed for 3 years. RESULTS: There were no differences in weight, age, or BMI preoperatively. There were no differences between the two groups at any follow-up time point from 6 months to 3 years. Follow-up was 100%. CONCLUSION: Due to the large standard deviations present in both groups, there was no statistical difference between either of the groups in terms of weight loss.

The effect of stoma size on weight loss after laparoscopic gastric bypass surgery: results of a blinded randomized controlled trial.

BACKGROUND: To determine the effect of different stoma sizes on the percent excess weight loss (%EWL) following laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP). METHODS: Blinded randomized prospective controlled study in two American Society for Bariatric Surgeons-designated Centers of Excellence hospitals. Two hundred gastric bypass patients between January 2005 and September 2005 were prospectively randomized into two groups of 100 patients each in the operating room, after the induction of anesthesia. Patients underwent LRYGBP with different stapler sizes of 21 and 25 mm for gastrojejunal (GJ) anastomosis from January 2005 to September 2005. Postoperative %EWL following LRYGBP in both patient groups were calculated using a multivariable linear mixed-effects model with an unstructured covariance matrix and a logistic regression was used to measure clinical comorbidities. RESULTS: Applying multivariable mixed models and logistical regression, circular stapler size of 21 and 25 mm, which predicted the need for dilations (odds ratio = 0.489), did not predict weight loss. The only predictors of weight loss were male gender and higher initial weight (p < 0.001). Follow-up at 2 years in the 21- and 25-mm groups was 68% and 66%, respectively. Both groups had > 80% EWL at 2 years. CONCLUSION: The level of restriction or the presence of stenosis achieved by different circular stapler sizes does not have a significant causative role in weight loss.

A randomized trial of bupivicaine pain pumps to eliminate the need for patient controlled analgesia pumps in primary laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The use of a bupivicaine pain pump has previously been reported to lower costs to hospitals, while providing similar pain relief to opioid-based patient controlled analgesia (PCA) pumps. However, these benefits have not been investigated in laparoscopic bariatric surgery. METHODS: We prospectively randomized 40 laparoscopic Roux-en-Y gastric bypass (LRYGBP) patients into two groups. The first group received the ON-Q bupivicaine pain pump placed subxiphoid and radiating in both directions caudally beneath the lowest rib. The second group was treated with a meperidine PCA, which was initiated in the PACU and discontinued at 06:00 hrs the following morning. Both groups had identical surgery, anesthesiologists, anesthesia protocol and postoperative nausea prophylaxis. RESULTS: There were no significant differences between the groups with regard to age, sex, pain scores, nausea scores, gas pain scores, antiemetic use throughout their stay, or opioid use in the PACU. However, there was a dramatic decrease in opioid use between the two groups over the time interval from leaving the PACU to 06:00 hrs (meperidine by PCA mean 217 mg vs ON-Q 129 mg meperidine equivalents, P=0.008). CONCLUSIONS: The use of a bupivicaine pain pump offers the opportunity to dramatically reduce the use of opioids postoperatively in all bariatric patients by eliminating PCA. This change could potentially reduce the incidence of respiratory failure from oversedation, while offering the same levels of pain control.

A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band patients in a single US center with three-year follow-up.

BACKGROUND: Open or laparoscopic Roux-en-Y gastric bypass (RYGBP) is the most common operation for treatment of morbid obesity in USA. The laparoscopic adjustable gastric band (LAGB) has been the most common bariatric operation performed worldwide. The LapBand was approved for use in USA in July 2001. Since then, several US surgeons have adopted one procedure preferentially over the other, and several have reported patient outcomes. We added the option of the LAGB to the RYGBP in our practice in July 2001. We hypothesized that both procedures will provide similar weight loss and co-morbidity reduction if followed for a sufficient length of time. To enhance weight loss, we adopted a patient behavioral program that is easy to remember, in an attempt to ensure a reduction in caloric intake and reduce hunger regardless of the operation performed. METHODS: A case-controlled matched-pair cohort study was conducted. All patients who presented to the Surgical Weight Control Center of Las Vegas between Aug 2001 and Aug 2004 for LAGB were placed into one group, and a matched-pair RYGBP cohort group was created. Patients in the RYGBP cohort were matched for age, sex, date of surgery, and BMI. All patients were evaluated on an intention to treat basis. Data were collected prospectively and analyzed retrospectively. All patients were subjected to the same preoperative education regarding calorie reduction behaviors and diet change, and received the same postoperative counseling regarding long-term eating behavior and food choices. RESULTS: During this period, 208 patients underwent LAGB and 600 underwent RYGBP. Of the 208 LAGB patients, 181 had suitable open or laparoscopic RYGBP matches. The two groups were similar in terms of age, sex, BMI, and co-morbidities. There were no deaths in either group. Resolution of co-morbidities statistically favored RYGBP as did the weight loss, over the study period. CONCLUSION: When patients are matched with 3-year follow-up according to time of surgery, age, sex and BMI, LRYGBP provides superior weight and co-morbidity reduction and can be done without severe complications. However, the LAGB is an effective weight loss tool and not every patient wishes to have the LRYGBP.

Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass.

PURPOSE: Many women with polycystic ovarian syndrome (PCOS) are overweight. This study investigated the impact of weight loss surgery on the clinical manifestations of this disorder in morbidly obese women with PCOS-a major risk factor for the development of heart disease, stroke, and type II diabetes. METHODS: We reviewed the outcomes of women diagnosed with PCOS who had undergone weight loss surgery at the University of Pittsburgh between July 1997 and November 2001. We evaluated the changes in menstrual cycles, hirsutism, infertility, and type II diabetes. RESULTS: A total of 24 women with PCOS were included in the study. Their mean age was 34 +/- 9.7 years. The mean preoperative body weight was 306 +/- 44 lb, with a body mass index of 50 +/- 7.5. All patients were oligomenorrheic. Of the 24 patients, 23 were hirsute. All women underwent elective laparoscopic gastric bypass surgery. The mean follow-up period was 27.5 +/- 16 months. The mean excess weight loss at 1 year of follow-up was 56.7% +/- 21.2%. All women resumed normal menstrual cycles after a mean of 3.4 +/- 2.1 months postoperatively. Of the 23 women with hirsutism, 12 (52%) had complete resolution at a mean follow-up of 8 +/- 2.3 months, 6 (25%) had moderate resolution at a mean of 21 +/- 18 months, and 3 had minimal resolution at 34 +/- 14 months. Two women reported no change in their hirsutism at 32 +/- 7 months. Five women were able to conceive after surgery without the use of clomiphene. CONCLUSION: Gastric bypass surgery and its consequent weight loss results in significant improvement of multiple clinical problems related to PCOS.

Weight loss, quality of life and employment status after Roux-en-Y gastric bypass: 5-year analysis.

BACKGROUND: Obesity can have a tremendous impact on the psychosocial, physical, and economic health of those afflicted by it. We hypothesized that if surgery results in significant weight loss and improves quality of life, those unemployed and disabled as a result of their morbid obesity might be more likely to become gainfully employed after Roux-en-Y gastric bypass (RYGBP). METHODS: We reviewed the medical charts of all patients who underwent RYGBP from April 1998 to December 1999. Demographics and employment status were obtained, along with preoperative weight, body mass index, Short Form 36 Health Survey and Beck Depression Inventory-II scores. For those employed, the recuperation time was also analyzed. Statistical analysis was performed using Student's t test and analysis of variance. RESULTS: Fifty-seven patients underwent RYGBP. Of the 57 patients, 41 were selected for analysis, 34% of whom were employed, with a mean recuperation time of 3.5 weeks. Their mean age was 32.4 years. The mean body mass index was 53.4 kg/m(2) preoperatively and 31.2 kg/m(2) at 5 years. Of the 41 patients, 27 (66%) were receiving disability and 25 (61%) attributed their disability to their morbidly obese state. At 5 years, 4 (16%) of the 25 were gainfully employed and no longer receiving public assistance. CONCLUSION: Despite successful long-term weight loss and improvement in quality of life, many morbid obesity patients do not return to gainful employment in the workforce after RYGBP. The mean body mass index was greater in the unemployed group at both 1 and 5 years, but the difference was not statistically significant. The socioeconomic impact of morbid obesity persists long after a reduction in weight and improvement in quality of life.

The chronic inflammatory hypothesis for the morbidity associated with morbid obesity: implications and effects of weight loss.

BACKGROUND: Obesity is a worldwide pandemic that causes a multitude of co-morbid conditions.However, there has been slow progress in understanding the basic pathophysiology that underlies co-morbid conditions associated with obesity. Recently, there has been intense interest in the role of inflammation in obesity. Using the inflammatory hypothesis, many of the mechanisms by which co-morbid conditions are associated with obesity are being elucidated. METHODS: We searched the literature and reviewed all relevant articles. We focused on hormones and cytokines that have been associated with other inflammatory conditions such as sepsis and systemic inflammatory response syndrome. FINDINGS: Angiotensinogen (AGT), transforming growth factor beta (TGFbeta), tumor necrosis factor alpha (TNFalpha), and interleukin six (IL-6) are all elevated in obesity and correlate with several markers of adipocyte mass. These mediators have detrimental effects on hypertension, diabetes, dyslipidemia, thromboembolic phenomena, infections, and cancer. Weight loss results in a reduction of inflammatory mediators and a diminution of the associated co-morbid conditions. CONCLUSIONS: The success of weight loss surgery in treating the complications associated with obesity is most probably related to the reduction of inflammatory mediators. While some aspects of bariatric physiology remain unclear, there appears to be a strong association between obesity and inflammation, thereby rendering obesity a chronic inflammatory state. A clearer understanding of the physiology of obesity will allow physicians who treat the obese to develop better strategies to promote weight loss and improve the well-being of millions of individuals.

Results of laparoscopic gastric bypass in patients with cirrhosis.

BACKGROUND: The safety and efficacy of bariatric surgery in patients with cirrhosis has not been well studied. METHODS: A retrospective review was conducted of patients with cirrhosis who underwent weight-loss surgery at a single institution. RESULTS: Out of a total of 2119 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), 30 patients (1.4%) with cirrhosis were identified. When compared with the entire cohort, patients with cirrhosis were significantly more prone to be heavier (BMI 53 vs 48), older in years (age 50 vs 45), more likely to be male (RR=1.3), and have a higher incidence of diabetes (70% vs 21%) and hypertension (67% vs 21%), P<0.05. The diagnosis of cirrhosis was made intra-operatively in 90% of patients. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. Early complications occurred in 9 patients and included anastomotic leak (1), acute tubular necrosis (4), prolonged intubation (2), ileus (1), and blood transfusion (2). Mean length of hospital stay was 4 days (2-18). There was one late unrelated death and one patient with prolonged nausea and protein malnutrition. The average follow-up time was 16 months (1-48). For patients >12 months postoperatively (n=15), the average percent excess weight loss was 63+/-15%. CONCLUSION: Laparoscopic RYGBP in the cirrhotic patient has an acceptable complication rate and achieves satisfactory early weight loss. Patients tend to be heavier, older, male and more likely to have diabetes and hypertension. Long-term studies are necessary to examine how weight loss impacts established cirrhosis.

DRG, costs and reimbursement following Roux-en-Y gastric bypass: an economic appraisal.

BACKGROUND: There is disagreement regarding hospital and physician reimbursement fees when DRG codes are used. We have found that physicians and hospitals are rewarded differently depending on the type of insurance coverage - per diem HMO (Health Maintenance Organization) vs public. METHODS: 133 patients were retrospectively analyzed in a single institution. There were 59 privately-insured and 74 publicly-insured patients. Using DRG 288, hospital and surgeon reimbursement rates, complications, length of stay, blood loss and basic demographics were evaluated on all patients. Reimbursement rates were then compared to inpatient hospital costs per case for both open and laparoscopic Roux-en-Y gastric bypass (RYGBP). Statistical analysis used Student's t-test and standard deviation. RESULTS: The 2 groups were similar in terms of age, sex and BMI. There was a large difference in physician reimbursement when comparing public to private insurance (931 US dollars +/-73 vs 2356 US dollars +/-822, P<0.001). Likewise, there was a large difference in hospital reimbursement (public 11773 US dollars +/- 4462 vs private 4435 US dollars +/- 3106, P<0.001). The estimated costs for open gastric bypass was 3179 US dollars vs 4180 US dollars for the laparoscopic bypass. The HMO per diem rate was 1000 US dollars per day. CONCLUSION: There is a relative disincentive for surgeons to treat publicly-insured patients, while there is an incentive for hospitals to treat those patients. The converse is true for the privately-insured patients. This dichotomy will impede the development of new centers and place greater burden on bariatric surgeons to reduce cost by performing the open RYGBP.

Duodenal varices: a novel treatment and literature review.

Hemorrhage associated with duodenal varices is an uncommon but often fatal manifestation of portal hypertension. We report a case of duodenal varices, review the literature, and present a new treatment modality. A 63-year-old man presented with hematemesis and hematochezia. An upper gastrointestinal endoscopy revealed hemorrhage from the duodenal varices that was initially controlled with injections of epinephrine. However, this was only partially successful, as the patient had repeated episodes of bleeding that was not amenable to injection sclerotherapy. The patient was taken emergently to the operating room after endoscopy failed to control the hemorrhage. The bleeding was controlled with simple oversewing of the duodenal varices through a duodenotomy. Three years later the patient remains symptom free. We propose that simple oversewing of duodenal variceal veins combined with a beta-blocker is an effective treatment for duodenal variceal hemorrhage.

Preperitoneal herniation into a laparoscopic port site without a fascial defect.

BACKGROUND: Port site herniation is an uncommon event that usually occurs as a result of incomplete fascial closure. This allows the omentum or viscera to herniate through the incompletely closed defect. However, in laparoscopic surgery for morbid obesity, the omentum and viscera can herniate through the thick preperitoneal space even with a complete closure of the fascia. CASE REPORT: A 19-year-old female with BMI 55 underwent uneventful long limb laparoscopic Roux-en-Y gastric bypass. On postoperative day 1 the patient had limited pain, was ambulating well, and was tolerating slps of liquids. A limited upper GI series performed on postoperative day 2 revealed no leak or obstruction. Several hours later the patient developed abdominal pain associated with nausea, which progressed to vomiting. CT of the abdomen suggested a port site herniation into the left subcostal port. The cause of the obstruction appeared to be herniation through the left subcostal port site. At laparotomy, a segment of bowel just distal to the anastomosis was found herniated through the port site. The Richter's hernia was reduced. Careful inspection of the fascia revealed a complete fascial closure, with the strangulated portion of the bowel incarcerated in the preperitoneal space. Following repair of the preperitoneal defect, her subsequent recovery was unremarkable. CONCLUSION: Laparoscopic surgery for morbid obesity presents the possibility for preperitoneal herniation. Closure, using a fascial closure device, under laparoscopic control, may offer a solution by closing both the fascia and peritoneum all at once.