Resolution of Hyperandrogenism, Insulin Resistance and Acanthosis Nigricans (HAIR-AN) Syndrome After Sleeve Gastrectomy.

Hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN) is a severe subphenotype of polycystic ovary syndrome (PCOS). A 32-year-old woman with HAIR-AN and class 3 obesity presented to an endocrinology clinic after she failed sequential trials of treatment with metformin, estrogen-progestin OCP, spironolactone, leuprolide, and a levonorgestrel intrauterine device. She complained of hirsutism and acanthosis nigricans severely affecting her quality of life and had secondary amenorrhea. Laboratory evaluation showed extremely elevated testosterone and insulin levels and elevated glycated hemoglobin A1c (HbA1c). She underwent laparoscopic sleeve gastrectomy. One year after the surgery, she lost 32% of her body weight and reported normalization of menses, dramatic improvement in hirsutism, and near-resolution of acanthosis nigricans. Her testosterone, insulin, and HbA1c normalized. This case demonstrates the central role of hyperinsulinemia in HAIR-AN and suggests that aggressive measures to normalize insulin resistance and reduce excess weight can effectively treat the reproductive abnormalities in this syndrome. We suggest that bariatric surgery can be an effective cure for HAIR-AN syndrome and that PCOS, including HAIR-AN, should be considered a comorbidity of obesity during evaluation of bariatric surgery candidates.

Predictors of 30-day follow-up visit completion after primary bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.

BACKGROUND: Adherence to follow-up visits is often unsatisfactory after bariatric surgery. OBJECTIVES: To identify predictors, including surgery type and preoperative demographics, body mass index (BMI), medical conditions, and smoking status, of 30-day follow-up visit completion. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers (2015-2018). METHODS: Patients who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy were included in this analysis. Data were analyzed using weighted logistic regression. Subanalyses included stratification of the sample by sex and age (<45, 45-60, and >60 years). RESULTS: Patients (n = 566,774) were predominantly female (79.6%), White (72.4%), non-Hispanic (77.9%), and middle-aged (44.5 ± 11.9 years), with a mean BMI of 45.3 ± 7.8 kg/m2. More than 95% of patients completed the 30-day visits. In the whole-sample analysis, older age (odds ratio [OR], 1.02) and the presence of non-insulin-dependent diabetes (OR, 1.04), hypertension (OR, 1.03), hyperlipidemia (OR, 1.10), obstructive sleep apnea (OR, 1.15), and gastroesophageal reflux disease (OR, 1.16) were positive predictors of the 30-day visit completion (Ps < .01). Conversely, sleeve gastrectomy procedure (OR, .86), Black race (OR, .87), Hispanic ethnicity (OR, .94), and the presence of insulin-dependent diabetes (OR, .96) and smoking (OR, .83) were negative predictors (Ps < .01). Several differences emerged in subanalyses. For example, in sex stratification, Hispanic ethnicity lost its significance in men. In age stratification, BMI and male sex emerged as positive predictors in the age groups of <45 and 45-60 years, respectively. CONCLUSION: Although challenged by small effect sizes, this analysis identified subgroups at a higher risk of being lost to follow-up after bariatric surgery.

Cellular Uptake and Photo-Cytotoxicity of a Gadolinium(III)-DOTA-Naphthalimide Complex "Clicked" to a Lipidated Tat Peptide.

A new bifunctional macrocyclic chelator featuring a conjugatable alkynyl-naphthalimide fluorophore pendant group has been prepared and its Gd(III) complex coupled to a cell-penetrating lipidated azido-Tat peptide derivative using Cu(I)-catalysed "click" chemistry. The resulting fluorescent conjugate is able to enter CAL-33 tongue squamous carcinoma cells, as revealed by confocal microscopy, producing a very modest anti-proliferative effect (IC50 = 93 µM). Due to the photo-reactivity of the naphthalimide moiety, however, the conjugate's cytotoxicity is significantly enhanced (IC50 = 16 µM) upon brief low-power UV-A irradiation.

Luminescent Alkyne-Bearing Terbium(III) Complexes and Their Application to Bioorthogonal Protein Labeling.

Two new bifunctional macrocyclic chelate ligands that form luminescent terbium(III) complexes featuring an alkyne group for conjugation to (bio)molecules via the Cu(I)-catalyzed "click" reaction were synthesized. Upon ligation, the complexes exhibit a significant luminescent enhancement when excited at the λ(max) of the "clicked" products. To demonstrate the utility of the complexes for luminescent labeling, they were conjugated in vitro to E. coli aspartate/glutamate-binding protein incorporating a genetically encoded p-azido-L-phenylalanine or p-(azidomethyl)-L-phenylalanine residue. The complexes may prove useful for time-gated assay applications.

Zwitterionic-coated "stealth" nanoparticles for biomedical applications: recent advances in countering biomolecular corona formation and uptake by the mononuclear phagocyte system.

Nanoparticles represent highly promising platforms for the development of imaging and therapeutic agents, including those that can either be detected via more than one imaging technique (multi-modal imaging agents) or used for both diagnosis and therapy (theranostics). A major obstacle to their medical application and translation to the clinic, however, is the fact that many accumulate in the liver and spleen as a result of opsonization and scavenging by the mononuclear phagocyte system. This focused review summarizes recent efforts to develop zwitterionic-coatings to counter this issue and render nanoparticles more biocompatible. Such coatings have been found to greatly reduce the rate and/or extent of non-specific adsorption of proteins and lipids to the nanoparticle surface, thereby inhibiting production of the "biomolecular corona" that is proposed to be a universal feature of nanoparticles within a biological environment. Additionally, in vivo studies have demonstrated that larger-sized nanoparticles with a zwitterionic coating have extended circulatory lifetimes, while those with hydrodynamic diameters of ≤5 nm exhibit small-molecule-like pharmacokinetics, remaining sufficiently small to pass through the fenestrae and slit pores during glomerular filtration within the kidneys, and enabling efficient excretion via the urine. The larger particles represent ideal candidates for use as blood pool imaging agents, whilst the small ones provide a highly promising platform for the future development of theranostics with reduced side effect profiles and superior dose delivery and image contrast capabilities.

Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment.

BACKGROUND: Internal hernia (IH) and Roux limb compression (RC) are recognized complications after retrocolic laparoscopic Roux-en-Y gastric bypass for obesity. The aim of the present study was to systematically identify the surgical technical errors leading to these complications. METHODS: An observational clinical human reliability assessment approach was used to analyze the operating videos of 3 groups: an IH group (n = 12), a Roux compression group (n = 13), and a control group (no complications, n = 21). Two investigators, unaware of the outcomes, reviewed all videos, using special rating software. All errors were categorized using the external error mode system and further described if a direct consequential error (e.g., bleeding) was found. RESULTS: An analysis of data showed that, on average, more errors occurred in the complication groups than in the control group (IH 5.85, Roux compression 3.54, control .90, P < .001). The strongest differences were found for missing intermesenteric stitches on both sides of the Roux limb. Logistic regression analysis showed that a missed stitch between the mesentery of the Roux limb and the transverse mesocolon was an independent predictor for IH (B = 1.727, P = .025). No technical or consequential errors could be identified as responsible for RC. CONCLUSION: The observational clinical human reliability analysis is a useful method to identify operative failure. For retrocolic, retrogastric laparoscopic Roux-en-Y gastric bypass, a systematic approach for the closure of the transverse mesenteric window might prevent IH complications.

Nanomaterials: applications in cancer imaging and therapy.

The application of nanomaterials (NMs) in biomedicine is increasing rapidly and offers excellent prospects for the development of new non-invasive strategies for the diagnosis and treatment of cancer. In this review, we provide a brief description of cancer pathology and the characteristics that are important for tumor-targeted NM design, followed by an overview of the different types of NMs explored to date, covering synthetic aspects and approaches explored for their application in unimodal and multimodal imaging, diagnosis and therapy. Significant synthetic advances now allow for the preparation of NMs with highly controlled geometry, surface charge, physicochemical properties, and the decoration of their surfaces with polymers and bioactive molecules in order to improve biocompatibility and to achieve active targeting. This is stimulating the development of a diverse range of nanometer-sized objects that can recognize cancer tissue, enabling visualization of tumors, delivery of anti-cancer drugs and/or the destruction of tumors by different therapeutic techniques.

A facile, click chemistry-based approach to assembling fluorescent chemosensors for protein tyrosine kinases.

A group of fluorophore-labeled peptide substrates of Src kinases have been synthesized with the aid of click chemistry. Some of the generated peptides exhibit an increase in fluorescence upon phosphorylation and are capable of detecting Src kinases with high sensitivity and specificity. Their availability permits real-time activity measurement of aberrantly activated oncogenic Src kinases in the crude lysate of chronic myelogenous leukemia cells. These new chemosensor peptides are highly useful tools that can be used for high-throughput screening to search for small molecule inhibitors of Src kinases as potential therapeutics for cancer treatment.

Breast cancer and bariatric surgery: temporal relationships of diagnosis, treatment, and reconstruction.

BACKGROUND: Given the increased prevalence of bariatric surgery, a certain number of women will develop breast cancer before or after bariatric intervention. Whether bariatric surgery reduces the risk of breast cancer remains uncertain. Similarly, reconstructive options for these patients and timing of reconstruction relative to their weight loss have not been established. METHODS: Patients who underwent bariatric procedures from 1992 to 2007 and were diagnosed with breast cancer from 1988 to 2007 were assessed. Outcome measures included age, body mass indices, timing of cancer diagnosis, type of bariatric procedure, treatment and reconstructive modalities, postoperative complications, and comorbidities. RESULTS: A total of 2878 women underwent bariatric procedures and 112,085 women had breast cancer diagnoses. Thirty-six women had breast cancer diagnosed before (group I) and 13 after bariatric surgery (group II) (p < 0.001). Group I had a mean age of 49.4 years and mean body mass index of 56.3. One woman underwent unilateral autologous/implant reconstruction followed by bariatric surgery and subsequently required revision. Three women in group II (mean age at diagnosis, 48.3 years; mean pre-weight loss body mass index, 53.5; mean body mass index at diagnosis, 32.9; mean time from bariatric surgery, 33 months; mean follow-up from reconstruction, 18 months) underwent autologous free tissue reconstruction; one required two revisions because of further weight loss. CONCLUSIONS: Complication profiles related to reconstruction may be compounded by timing of bariatric surgery and subsequent weight loss. Further multicenter prospective analysis should aid in assessing cancer risk after weight loss along with timing of reconstruction to optimize outcomes in this population.

Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass.

BACKGROUND: Internal hernias (IHs) can complicate laparoscopic Roux-en-Y gastric bypass (LRYGB). A number of radiological investigations can be used in the diagnosis. These include plain X-rays, upper gastrointestinal (UGI) series, ultrasound, and computed tomography (CT) scanning. We present radiological findings in our series of 58 symptomatic internal hernias based on our 6-year experience (2000-2006) of 2,572 LRYGB patients. METHODS: A retrospective chart review was performed of all patients undergoing LRYGB who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. Types of radiological tests performed and their results were recorded. RESULTS: Fifty-eight symptomatic internal hernias were recorded, of which 56/58 (97%) underwent radiological investigation; 2/58 went directly to surgery. Of the 56 patients who underwent diagnostic imaging, 41 plain abdominal X-rays, 37 CT scans, 26 UGI series, and eight ultrasound scans were performed. Sixty-five percent of UGI series and 92% of CT scans had positive features diagnostic of internal hernia. Performing both CT and UGI series successfully diagnosed IH in 100% of cases. Subgroup analysis did not reveal any association between positive result of imaging test and type of internal hernia. CONCLUSION: CT scanning is the single most effective radiological investigation for diagnosing internal hernias post-LRYGB. In non-diagnostic cases, the addition of an upper GI series increases the diagnostic rate to 100%.

Laparoscopic Roux-en-Y gastric bypass and its early effect on blood pressure.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery is known to have a significant effect on obesity-related comorbidities such as hypertension curing it in some (50-70%) while improving control in others. Our aim was to observe the changes in blood pressure (BP) in a cohort of 100 patients followed prospectively for 1 year after LRYGB. METHODS: BP measurements were recorded prospectively in 100 consecutive patients preoperatively and then postoperatively at weeks 1, 5, 9, and months 6 and 12. In order to reduce bias, three BP measurements were made by the same nurse at each office visit and the mean recorded. Pre- and postoperative usage of antihypertensive medication was also noted. RESULTS: Eighty-nine women and 11 men underwent LRYGB and their BP monitored for 1 year. There was an 85% follow-up rate with mean % excess body weight loss of 60. Reductions in systolic (9 mmHg) and diastolic (7 mmHg) BP measurements were seen as early as week 1 postoperatively and maintained for the duration of the observation period (P < 0.05). Furthermore, postoperative usage of antihypertensive medication is reduced to a third of preoperative use. CONCLUSION: LRYGB is associated with an early reduction in BP and antihypertensive medication usage which is maintained at 1 year after surgery. This early impact on blood pressure occurs before any significant weight loss is achieved thereby suggesting a hormonal mechanism that may be involved for the changes observed.

Roux limb obstruction secondary to constriction at transverse mesocolon rent after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Partial small bowel obstruction can occur as a result of circumferential extrinsic compression of the Roux limb as it traverses the transverse mesocolic rent from thickened cicatrix formation in this area. The aim of this study is to examine the incidence of Roux limb compression with particular attention to the timing of presentation and associated weight loss in the setting of a university hospital in the United States. METHODS: A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass who developed symptomatic small bowel obstruction requiring operative intervention from January 1, 2000 and September 15, 2006. RESULTS: Of 2215 patients, 20 (.9%) developed symptomatic Roux limb compression. The mean time to presentation was 48 days after LRYGB. By this stage, the mean percentage of excess body weight loss was 29%. Of the 20 patients, 19 underwent an upper gastrointestinal contrast study, the results of which confirmed the diagnosis. In all cases, laparoscopic intervention was successful in freeing the constricted Roux limb by dividing the cicatrix formation between the Roux limb and mesocolic window. Switching from continuous to interrupted closure of the space between Roux limb and mesocolic window appeared to reduce the incidence of this complication (P<.05). CONCLUSION: Narrowing at the transverse mesocolon rent is an uncommon cause of small bowel obstruction after retrocolic laparoscopic Roux-en-Y gastric bypass. Unlike internal hernias, which tend to occur later in the clinical course and are associated with significant weight loss, Roux limb obstruction occurs earlier after gastric bypass and is not associated with significant weight loss. Interrupted closure of the mesocolic window might reduce the risk of Roux compression.

Patterns of plastic surgical use after gastric bypass: who can afford it and who will return for more.

BACKGROUND: More patients are undergoing plastic surgery after gastric bypass. Socioeconomic factors influencing the decision to have body contouring after gastric bypass have not been studied in the current literature. METHODS: In this study, 2501 consecutive gastric bypass patients were surveyed. Outcome variables were assessed by univariate and multivariable analyses. RESULTS: Nine hundred twenty-six patients (817 women and 109 men) responded (40.3 percent of the 2296 surveys that at least may have been received), with a mean follow-up of 2.4 years. One hundred five (11.3 percent) underwent body contouring. Thirty-four patients assumed all costs for body contouring, and of these, 47 percent had multiple operations. Sixty-eight patients had some insurance coverage; 26 percent of these patients personally paid for additional body contouring. Having multiple procedures was not explained by any variables in our model. Body contouring was related to years since gastric bypass (p < 0.0001), post-gastric bypass body mass index (p < 0.03), change in body mass index (p < 0.0001), open versus laparoscopic gastric bypass (p < 0.0001), and income category greater than $20,000 (p < 0.03). Expenditures for body contouring were greater if the patient assumed costs versus had some insurance (p < 0.03), but were not related to income. Patients who assumed all costs of body contouring had lower pre-gastric bypass and post-gastric bypass body mass indexes (p < 0.007). CONCLUSIONS: A minority of patients underwent body contouring. Patients assuming the costs of body contouring were twice as likely to have additional surgery. These results suggest that socioeconomic factors play an important role in the decision to have body contouring but may not predict who will have concomitant or additional procedures.

Post-bariatric surgery reconstruction: patient myths, perceptions, cost, and attainability strategies.

BACKGROUND: A discrepancy exists between patient perceptions of post-bariatric surgery reconstruction and cost, value, and ultimate attainability. The authors investigated prospective gastric bypass patients to identify misconceptions and strategies to aid in the attainability of post-bariatric surgery reconstruction. METHODS: One hundred seventy-six prospective gastric bypass patients were surveyed for perceptions of plastic surgery, a "club" concept integrating plastic surgical/bariatric teams, and payment strategies. Cost comparisons were set up for comparison with major consumer purchases. Outcome measures were assessed by univariate analyses. RESULTS: One hundred seventy-four patients (139 women and 35 men; mean age, 42.3 years; mean body mass index, 49.3) completed the survey; 65.9 percent expressed an interest in plastic surgery (women were more interested than men) (p < 0.05); 73.1 percent wanted their plastic surgeon affiliated with the bariatric surgeon/team; 47 percent wanted to meet the plastic surgeon before their gastric bypass; and 14.4 percent equated the cost of a total body lift to the cost of a new car versus 31.9 percent for a trip to Disneyworld, 23.8 percent for a television, and 16.3 percent for a radio. Estimated costs for plastic surgery were undervalued by 60 percent. Sixty percent were interested in a club with a monthly fee that would go toward future plastic surgery. Other payment strategies were less popular. None of the independent variables predicted the degree of interest in any particular plan. CONCLUSIONS: Future gastric bypass patients, particularly women, are a unique population with common misconceptions regarding post-bariatric surgery reconstruction. Early patient education and financial awareness, in combination with preexisting or newly created bariatric centers, may improve attainability for this population.

Temporal and demographic factors influencing the desire for plastic surgery after gastric bypass surgery.

BACKGROUND: An increasing number of gastric bypass patients desire plastic surgery after massive weight loss. However, the timing of interest and factors influencing the desire for body contouring have not been studied. METHODS: Two thousand five hundred one gastric bypass patients were surveyed. Outcome measures included years since gastric bypass, laparoscopic versus open procedures, body mass indexes, income, prior plastic surgery, desire for body contouring, and need for a payment plan. Multiple variables were assessed by univariate and multivariate analysis. RESULTS: Nine hundred twenty-six patients (817 women and 109 men; mean age, 47.2 years) responded. Eight hundred eleven patients were considering body contouring: 685 patients (84.5 percent) desired body contouring after gastric bypass and 126 wanted no further surgery (15.5 percent). Desire was inversely related to age (p < 0.0001), years since gastric bypass (p = 0.052), and open versus laparoscopic gastric bypass (p = 0.04), but was two times more likely in women (p = 0.008) and divorced versus married individuals (p = 0.04). Patients desiring a payment plan were younger (p = 0.0210) and had lower post-gastric bypass body mass indexes (p = 0.007). Age was inversely related to desire for a payment plan but directly related to the inability to afford or lack of desire for body contouring (p = 0.02). CONCLUSIONS: A majority of post-bariatric surgery patients desire body contouring; younger, divorced, female patients who had laparoscopic gastric bypass voiced the strongest interest in body contouring. Thus, efforts should be directed toward facilitating body contouring in this subpopulation because they appear the most motivated.

Bioabsorbable glycolide copolymer staple-line reinforcement decreases internal hernia rate after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Internal hernias (IHs) can occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP), perhaps because of a lack of adhesion formation at the cut edges of the mesentery and a cutting through of sutures with a decrease in fat from weight loss. In patients undergoing reoperation after LRYGBP, we observed that bioabsorbable glycolide copolymer staple-line reinforcement (SLR) placed to mitigate staple-line bleeding had evoked adhesiogenesis and tissue fusion at the mesentery edges; therefore, we investigated whether use of this material decreases post-LRYGBP IH rates. METHODS: The records of the 43 patients (3%) in whom an IH developed during a mean follow-up time of 2 years in a series of 1,704 LRYGBP procedures were reviewed retrospectively. RESULTS: The IHs were in the Peterson's space (n = 4), the enteroenterostomy (n = 17), or the transverse mesocolon (n = 22). The IH rate was significantly higher in patients who had suture closure of the mesenteric defects at LRYGBP than in those without formal closure of the defects but in whom SLR was applied to the edges of the cut mesentery (P = 0.01). The suture-closure and SLR groups had similar demographic, operative, and follow-up characteristics. When transverse mesocolic IHs were excluded from analysis, patients given SLR remained less likely to have an IH (P = 0.05). CONCLUSION: Use of bioabsorbable polymer SLR may decrease the occurrence of IHs after LRYGBP. Additional studies of the effect of mesentery closure method on IH incidence after LRYGBP are warranted.

Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically. The aim of this study was to see when internal hernias occur in relation to weight loss and time course after surgery. Furthermore, we wish to examine the impact of Roux limb positioning ante- versus retrocolic and whether switching to running versus interrupted closure of the mesenteric defects created at surgery made any difference. METHODS: A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. RESULTS: Fifty-four internal hernias occurred in 2,572 patients, an incidence of 2.1%. The site of internal hernias varied: 25 (1%), transverse mesocolon; 22 (0.8%), enteroenterostomy; 7 (0.3%), Peterson's space. The mean time to intervention for an internal hernia repair was 413 +/- 46 days and average % excess body weight loss (%EBWL) in this period was 59 +/- 3.3. Subgroup analysis demonstrates internal hernia incidence to be 2 in 357 (0.6%) in antecolic Roux versus 52 in 2,215 (2.4%) in retrocolic Roux limb (odds ratio = 4, P < 0.05). Continuous closure versus interrupted stitching of mesenteric defects does not seem to alter the incidence of internal hernias. CONCLUSION: This study demonstrates that the majority of internal hernias occur after a significant (>50%) EBWL. Furthermore, the antecolic approach is associated with a much reduced incidence of internal hernia.

Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management.

OBJECTIVE: To summarize our experience with small-bowel obstructions after laparoscopic Roux-en-Y gastric bypass. DESIGN: Retrospective record review. SETTING: University-affiliated hospital. PATIENTS: One hundred five consecutive patients undergoing surgery for intestinal obstruction after laparoscopic Roux-en-Y gastric bypass between May 24, 2001, and December 1, 2006. MAIN OUTCOME MEASURES: Common presenting symptoms, causes, yield of radiological studies, and types of surgical procedures performed for post-gastric bypass bowel obstruction. RESULTS: A total of 2325 laparoscopic Roux-en-Y gastric bypass procedures were performed during the study period. A total of 105 patients underwent 111 procedures. Bowel obstruction was confirmed in 102 patients, yielding an overall incidence of 4.4%. The most common presenting symptom was abdominal pain (82.0%), followed by nausea (48.6%) and vomiting (46.8%). Thirty-one patients (27.9%) presented with all of the 3 mentioned symptoms. The mean time to presentation was 313 days after bypass (range, 3-1215 days). Among the studies, results in 48.0% of computed tomographic scans, 55.4% of upper gastrointestinal studies, and 34.8% of plain abdominal radiography studies were positive for intestinal obstruction. In 15 patients (13.5%), all of the radiological study results were negative. The most common causes were internal hernias (53.9%), Roux compression due to mesocolon scarring (20.5%), and adhesions (13.7%). Laparoscopic explorations were carried out in 92 cases (82.9%). The incidences of bowel obstructions were 4.8% with retrocolic Roux placement and 1.8% with antecolic Roux placement. CONCLUSIONS: Altered gastrointestinal tract anatomy results in vague symptoms and a poor yield with imaging studies. A sound knowledge of altered anatomy is the key to correct interpretation of imaging studies and prompt diagnosis.

Cholecystectomy during laparoscopic gastric bypass has no effect on duration of hospital stay.

BACKGROUND: Laparoscopic cholecystectomy can be safely performed at the time of laparoscopic Roux-en-Y gastric bypass (LRYGBP). This study was primarily conducted to examine whether there is any difference in the length of hospital stay and duration of operation in patients who undergo concomitant cholecystectomy with their LRYGBP. In addition, the frequency and nature of complications in the two groups were compared. METHODS: Retrospective chart analysis and comparison of 200 patients who underwent LRYGBP alone with 200 patients who underwent LRYGBP with simultaneous cholecystectomy. RESULTS: Concomitant cholecystectomy did not increase length of hospital stay (2.04 +/- 0.20 days vs 2.06 +/- 0.29 days in the LRYGBP alone group, P = 0.43). Furthermore, the addition of cholecystectomy only added an extra 29 minutes to the operation (P < 0.01). In both groups, there was no difference in the rate of postoperative complications (8.5% in both groups, P = 0.21), the nature of which was more or less equally distributed amongst the two groups. CONCLUSION: Laparoscopic cholecystectomy performed at the time of LRYGBP does not alter length of hospital stay or frequency of postoperative complications and only adds an extra half hour to total operation time.

Accessing the common bile duct after Roux-en-Y gastric bypass.

We report on the clinical course of 2 patients who underwent laparoscopic Roux-en-Y gastric bypass for obesity and subsequently presented with biliary complications of choledocholithiasis in 1 case and sphincter of Oddi dysfunction in the other. The approach to these complex problems is described. Both patients underwent percutaneous transhepatic access to the common bile duct (CBD) for balloon sphincteroplasty. In 1 patient, percutaneous choledochoscopy was used for endoluminal visualization of the CBD. A literature review of the management of biliary problems after gastric bypass is presented. Although access to the CBD is limited, the options include percutaneous transhepatic instrumentation of the CBD, percutaneous or laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP), transenteric endoscopic cholangiopancreatography, ERCP using specialized endoscopes, and laparoscopic or open CBD exploration. Bile duct pathology after laparoscopic gastric bypass can be safely and effectively managed using a variety of techniques.