Intussusception after open Roux-en-Y gastric bypass managed with laparoscopic reduction.

Intussusception is a rare long-term complication following bariatric surgery. With unclear risk factors and a variable presentation, intussusception is often diagnosed in emergency departments on cross-sectional imaging. Due to the nature of the disease process, prompt involvement of a bariatric surgeon and operative intervention offers the best outcome. Here, we discuss two similar cases of jejunojejunal intussusception following open Roux-en-Y gastric bypass and abdominoplasty that were managed with operative reduction of the involved bowel.

Remodifying Omentopexy Technique Used with Laparoscopic Sleeve Gastrectomy: Does It Change any Outcomes?

BACKGROUND: Gastric obstructions, leaks and staple line bleeding are reported after laparoscopic sleeve gastrectomy (LSG). There is no ideal method or technique to avoid these mishaps. We added modified omentopexy (OP) to LSG to determine if there is any effect on gastric leaks and some other complications. METHODS: This single institution case control study included two groups of morbidly obese patients undergoing LSG. They were grouped as omentopexy (OP) or no omentopexy (NP). Patient characteristics such as age, sex, ASA (American Society of Anesthesiologists) risk, body mass index (BMI), nutritional status and comorbidities were comparable. Postoperative follow-up was scheduled at 1 week, 1 month, 3 months, 6 months and 12 months. All received standard postoperative clinical, nutritional evaluation and PPI therapy for at least 3 months. RESULTS: Total 737 patients underwent LSG from January 2012 to December 2017. Out of these, 370 that had OP and 367 that had NP were analyzed. NP group was subdivided into Lemberted Staple line (LS) and bioabsorbable staple line reinforcement (BSLR) groups. Gastric leaks and perforations were clubbed together as gastric disruptions (GD). Patients with at least 15 months of postoperative follow-up were included. Those who failed to follow up were excluded. GD was reported in 7 out of 367 NP patients (1.9%), while no GD was seen in 370 OP patients (P = 0.01). Bleeding was seen in 1 OP versus 2 NP patients (P = 0.6). Venous thromboembolism was reported in 2 OP versus 1 NP patients (P = 1). Wound infection was seen in 1 OP versus 2 NP patients (P = 0.6). Readmissions were noted in 2 OP versus 6 NP patients (P = 0.1). Pneumonia was seen in 2 OP and 2 NP patients (P = 1). Postoperative dehydration was seen in zero OP versus 1 NP patients (P = 0.4). Gastric obstruction was not seen in any of the patients. Postoperative gastric reflux was present in 49/370(13.2%) OP versus 57/367(15.4%) NP patients (P = 0.4). Within NP group, LS (Lemberting of Staple line) patients (286/367) had 4 GD (1.39%) versus no GD in OP (P = 0.03). BSLR (Bioabsorbable Staple line re-enforcement) patients (81/367) had 3 GD (3.7%) versus no GD in OP (P = 0.005). None of the groups had any mortality. CONCLUSIONS: GD (gastric disruptions) were statistically significant, but the following bleeding, venous thromboembolism and gastroesophageal reflux did not reach statistical significance, which indicates that OP, if performed correctly with LSG, has favorable effects on gastric leaks.

Effect of long-term proton pump inhibitor therapy on hemoglobin and serum iron levels after sleeve gastrectomy.

BACKGROUND: Iron deficiency anemia and iron deficiency are commonly seen after bariatric surgery. Gastroesophageal reflux disease is commonly associated with sleeve resections and warrants postoperative acid reducing therapy. OBJECTIVE: To analyze the impact of long-term proton pump inhibitors on iron deficiency or iron deficiency anemia in laparoscopic sleeve gastrectomy (LSG) patients. SETTING: University hospital, USA. METHODS: A single-institution case control study included 2 groups of bariatric patients who underwent LSG. Patient characteristics such as age, sex, American Society of Anesthesiologists risk, body mass index, nutritional status, and co-morbidities were comparable. Postoperative follow-up was scheduled at 1-week, and 1-, 3-, 6-, and 12-month durations. All received standard postoperative iron, multivitamin therapy, and nutritional screening and evaluation. All patients were placed on postoperative proton pump inhibitors (PPI) therapy for at least 3 months. At third postoperative visit, anemia indicators were assessed by serum iron concentration, total iron binding capacity, transferrin saturation, red blood cell count, hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin concentration. Postoperative hemoglobin and serum iron levels were compared between those patients still taking PPIs to those not taking PPIs at 12 months. RESULTS: A total of 287 patients underwent LSG from January 2016 to December 2017, 203 were included and 84 patients were excluded. Patients taking long-term PPIs (>12 mo, n = 85) were compared with those not taking PPIs (n = 118) and outcomes were respectively as follows: mean pre- and postoperative hemoglobin levels (in g/DL) were 13.2 and 10.7, and 13.3 and 13.7; mean postoperative serum iron levels (in µg/DL) were 41.7 and 88.7. Results were computed using paired t test and odds ratio that showed iron deficiency anemia in 12.9% (11/85) in PPI group compared with 4.23% (5/118) in the non-PPI group (odds ratio of 3.3, 95% confidence interval [1.21-10], and P = .03). Iron deficiency was seen in 22.3% (19/85) in the PPI group and 11% (13/118) in the non-PPI group (odds ratio of 2.3, 95% confidence interval [1.07-5.02] and P = .031). CONCLUSIONS: Our study indicates that PPIs can increase the severity of iron deficiency and iron deficiency anemia in patients who underwent LSG. Aggressive surveillance is needed in those taking long-term PPIs after LSG. It is encouraged to further analyze these findings in a larger randomized study model design.

An unusual case of perisplenic small bowel volvulus after laparoscopic Roux En Y gastric bypass.

Internal hernias (IH) are one of the dreadful complications of laparoscopic Roux En Y gastric bypass (LGBP). Commonly reported internal hernias (IH) following Roux En Y gastric bypass (LGBP) in the literature are meso-colic, meso jejunal and Peterson's space hernias. These patients may not have any definitive symptoms. Findings are often missed on radiological studies and a high index of clinical suspicion is often necessary. If in doubt, a timely diagnostic laparoscopy is critical to decrease morbidity and mortality in these patients. We present a very unusual case of peri-splenic small bowel herniation with volvulus following LGBP with indeterminate radiological findings. Our case emphasizes that early laparoscopy is both diagnostic and therapeutic for desirable clinical outcomes.

Complications at gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass: comparison between 21- and 25-mm circular staplers.

BACKGROUND: Complications involving the gastrojejunostomy (GJ) after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity frequently result in hospital readmission and additional procedures. The purpose of this study was to compare the complication rate of GJ performed with the 21- and 25-mm circular staplers. METHODS: We retrospectively reviewed the incidence of stricture, bleeding, ulcer, and leak at the GJ in 438 consecutive patients who had undergone LRYGB. RESULTS: The GJ was performed using the 25-mm stapler in 374 patients and the 21-mm stapler in 64 patients. Of the 50 anastomotic complications, 11 (17.2%) occurred with the 21-mm stapler, including 6 strictures (9.4%), 4 ulcers (6.3%), and 1 leak (1.6%), and 39 (10.4%) with the 25-mm stapler, including 11 strictures (2.9%), 6 acute bleeding episodes (1.6%), 19 ulcers (5.4%), and 4 leaks (1.1%). Rehospitalization was required in 9 patients (47%) with a pure stricture and 17 (74%) with ulcers. The incidence of pure stricture was significantly greater in the GJ performed with the 21-mm than with the 25-mm stapler (P = .026, Fisher's exact test). No difference was found in the rate of acute bleeding, leak, or ulcer between the 2 groups. All strictures resolved with balloon dilation. Four patients with stenotic ulcers that failed to respond to dilation and medications required operative revision. No difference was found in postoperative weight loss between the 2 groups. CONCLUSION: Anastomotic complications were recognized in 50 (11.4%) of 438 patients who had undergone LRYGB in which the GJ was performed using circular staplers, including 11 (17.2%) with the 21-mm and 39 (10.2%) with the 25-mm stapler. The rate of anastomotic stricture was significantly lower using the 25-mm circular stapler.

Patient characteristics impacting excess weight loss following laparoscopic adjustable gastric banding.

BACKGROUND: Weight loss is more variable after laparoscopic adjustable gastric banding (LAGB) than after gastric bypass. Subgroup analysis of patients may offer insight into this variability. The aim of our study was to identify preoperative factors that predict outcome. METHODS: Demographics, co-morbid conditions and follow-up weight were collected for our 1st 200 LapBand patients. Linear regression determined average %EWL. Logistic regression analysis identified factors that impacted %EWL. RESULT: 200 patients returned for 778 follow-up visits. Median age was 44 years (21-72) and median BMI 45 kg/m2 (31-76). 140 (80%) were women. Average %EWL was y % = 0.007 %/day (days since surgery) + 0.12% (correlation coef. 0.4823; P<0.001). %EWL at 1 year was 37%. The best-fit logistic regression model found 7 factors that significantly changed the odds of achieving average %EWL. Older patients, diabetic patients and patients with COPD had greater odds of above average %EWL. Female patients, patients with larger BMIs, asthmatic patients and patients with hypertension had increased odds of below average %EWL. CONCLUSION: Specific patient characteristics and comorbid conditions significantly altered the odds of achieving satisfactory %EWL following gastric banding.