Is a "retained fundus" seen on postoperative upper gastrointestinal series after laparoscopic sleeve gastrectomy predictive of inferior weight loss?

BACKGROUND: Postoperative upper gastrointestinal series (UGI) has never been shown to be effective in ruling out leaks or obstruction after gastric bypass or sleeve gastrectomy. In sleeve gastrectomies, UGI will define the shape of the sleeve and rule out a retained fundus that was not optimally excised during surgery. OBJECTIVES: We aimed to investigate the impact of a "retained fundus" on weight loss to determine whether UGIs can be used to gauge success of the operation and predict outcome. SETTING: Urban community teaching hospital, United States. METHODS: Retrospective study analyzing routine UGIs performed on 203 consecutive patients. Exclusion criteria included low quality UGI (absence of a still image of complete fill with contrast), revisions from gastric band to sleeve, absence of weight-loss data, postoperative leak, and postoperative stenosis. RESULTS: A total of 149 patients were included. Mean excess weight loss at one year for groups 1 through 4 was 67.3%, 72.7%, 67.8%, and 65.9%, respectively. There was no significant statistical difference in excess weight loss between the optimal group and the group of both mild and severe retained fundus (P = .22). The weight loss remained equivalent even when comparing the optimal sleeves with only those with severe retained fundus (P = .19). There was a statistically significant difference in quality of sleeve gastrectomies on UGI with surgical experience showing less retained fundus on the UGIs (P = .006) in the latter half of the series. CONCLUSION: Retained fundus does not seem to cause inferior weight loss in the early postoperative period. Thus, UGI cannot predict weight loss outcomes in the short term.

Factors influencing 30-day emergency visits and readmissions after sleeve gastrectomy: results from a community bariatric center.

INTRODUCTION: Bariatric surgery has proven safe and effective for long-term weight loss in morbidly obese patients. Readmissions within 30 days of discharge have become an important metric for quality of care. Sleeve gastrectomy is a common bariatric procedure, but data regarding early readmission is sparse. The purpose of this study is to determine what, if any, demographic or technical factors influence returns to the hospital or readmission following sleeve gastrectomy. METHODS: All laparoscopic sleeve gastrectomies (n = 200) performed at a single community hospital from February 2009 to November 2012 were retrospectively reviewed. Demographic, technical, length of stay, return to Emergency Department (ED) and readmission data were gathered for each patient. The data were analyzed to determine what factors were related to early return to the Emergency Department or readmission. RESULTS: Demographics were similar to other studies, with a male to female ratio of 1:4. Patients returning to the ED or readmitted within 30 days were statistically younger than those not returning. None of the other demographic, social, technical, or comorbid conditions considered were associated with a statistically significant risk of readmission or return to the ED within 30 days. CONCLUSION: Although the only statistically significant difference among the groups studied was age, trends toward significance exist in minority ethnicity and comorbid asthma. These factors have been associated with increased complications in other types of surgery. Larger, multi-institutional studies are needed to further evaluate these and other risk factors for readmission following bariatric surgery.

Pre-Lap-Band group education in Medicaid population: does it really make a difference?

BACKGROUND: The effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007. METHODS: A prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis. RESULTS: No significant difference was found in the mean baseline excess body weight between the 2 groups (74 +/- 20 kg in the SMPP-compliant and 76 +/- 20 kg in the non-SMPP-compliant participants). The mean baseline body mass index (47 +/- 7 versus 48 +/- 72 kg/m(2) for the SMPP-compliant and non-SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures). CONCLUSION: In a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Predictors of early quality-of-life improvement after laparoscopic gastric bypass surgery.

BACKGROUND: Quality of life is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on quality of life (QOL), along with their direct effect on diseases they are targeting. Similarly, in obesity, consensus has been reached on the importance of QOL as an independent outcome measure for obesity surgery along with weight loss and comorbidity. Therefore, the aim of this study was to assess the impact of patient demographics and comorbidities on short-term QOL improvement after laparoscopic gastric bypass (LGB) surgery. METHODS: The change in QOL after LGB was assessed in 171 patients (147 women, 24 men; mean age, 43.1 y) using the Short-Form-36 (SF-36) questionnaire. Multivariate logistic regression analysis was used to identify patients' demographics and comorbidities predictive of major QOL improvement. RESULTS: Body mass index decreased significantly at 3 months (48.5 +/- 5.8 to 38.4 +/- 5.4 kg/m2; P < .001) with excess weight loss of 37.4% +/- 9.2%. The SF-36 follow-up evaluation showed significant improvement (44.2 +/- 15.7 to 78.6 +/- 15.5; P < .001). A significant inverse correlation was found between QOL (before and after bypass) and the number of comorbidities (r = .29, P = .001; R = .22, P = .005; respectively), but the magnitude of QOL change did not correlate with the number of comorbidities (P = .5). When the entire cohort of patients was dichotomized according to their magnitude of change in SF-36 scores, the univariate analysis showed that the group of patients with no improvement or minor improvement in their SF-36 was characterized by a higher percentage of male sex and a lower prevalence of diabetes. These 2 preoperative factors remained statistically significant in the multivariate analysis. Preoperative diagnosis of type 2 diabetes increased the likelihood of major improvement in QOL after LGB by 6.2 times, whereas being a woman increased this likelihood by 16.1 times. CONCLUSIONS: Significant weight loss was achieved as early as 3 months after LGB, causing substantial improvement in QOL in more than 95% of patients. Women with type 2 diabetes have the highest odds to achieve a major QOL improvement after LGB and therefore they should represent the ideal target population for surgical weight loss programs.

The endoscopic radiofrequency approach to management of GERD.

PURPOSE OF REVIEW: Endoscopic treatment has been recently introduced as a new option for treating gastroesophageal reflux disease. In this article the authors review the radiofrequency approach known as the Stretta procedure, as more evidence has linked reflux to upper airway disease. RECENT FINDINGS: Since 1968, when laryngeal disorders were linked to gastroesophageal reflux disease, more upper airway diseases such as chronic laryngitis, subglottic stenosis, and even laryngeal carcinoma were found to be occasionally caused by extraesophageal reflux. Most otolaryngologists treat these patients with proton pump inhibitors, which improve symptoms in two thirds of patients. Antireflux surgery remains the treatment of choice, relieving symptoms in more than 90% of patients. Endoscopic treatment has recently emerged as an option for treatment of gastroesophageal reflux disease. The Stretta procedure delivers radiofrequency energy to the gastroesophageal junction. This has proved to be effective in controlling reflux by inhibiting transient, inappropriate lower esophageal sphincter relaxation, increasing postprandial lower esophageal spincter pressure, and decreasing lower esophageal sphincter compliance. Stretta is among the earliest endoscopic technologies to be approved by the Food and Drug Administration for the treatment of reflux. It has the longest term follow-up published to this date, and the most durable effect. It is performed under intravenous sedation on an outpatient basis and has a low incidence of complications. SUMMARY: The Stretta procedure is an endoscopic, noninvasive modality for the treatment of gastroesophageal reflux disease. It should be considered in the treatment of reflux-related upper airway diseases.