Amir Mehran

Is social support associated with greater weight loss after bariatric surgery?: a systematic review

Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post‐operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post‐operative weight loss (total n = 735 patients). All studies found a positive association between post‐operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non‐significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post‐operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post‐operative outcomes.

Management of Acute Bleeding after Laparoscopic Roux-en-Y Gastric Bypass

Background: The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. Material and Methods: The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. Results: 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. Conclusions: The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.

Does weight loss immediately before bariatric surgery improve outcomes: a systematic review

BACKGROUND Preoperative weight loss before bariatric surgery has been proposed as a predictive factor for improved patient compliance and the degree of excess weight loss achieved after surgery. In the present study, we sought to determine the effect of preoperative weight loss on postoperative outcomes. METHODS A search of MEDLINE was completed to identify the patient factors associated with weight loss after bariatric surgery. Of the 909 screened reports, 15 had reported on preoperative weight loss and the degree of postoperative weight loss achieved. A meta-analysis was performed that compared the postoperative weight loss and perioperative outcomes in patients who had lost weight preoperatively compared to those who had not. RESULTS Of the 15 articles (n = 3404 patients) identified, 5 found a positive effect of preoperative weight loss on postoperative weight loss, 2 found a positive short-term effect that was not sustained long term, 5 did not find an effect difference, and 1 found a negative effect. A meta-analysis revealed a significant increase in the 1-year postoperative weight loss (mean difference of 5% EWL, 95% confidence interval 2.68-7.32) for patients who had lost weight preoperatively. A meta-analysis of other outcomes revealed a decreased operative time for patients who had lost weight preoperatively (mean difference 23.3 minutes, 95% confidence interval 13.8-32.8). CONCLUSION Preoperative weight loss before bariatric surgery appears to be associated with greater weight loss postoperatively and might help to identify patients who would have better compliance after surgery.

Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass

BACKGROUND Obstructive sleep apnea (OSA) is prevalent in the morbidly obese population. The need for routine preoperative testing for OSA has been debated in bariatric surgery publications. Most investigators have advocated the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) in the postoperative setting; however, others have reported pouch perforations or other gastrointestinal complications as a result of their use. From a review of our experience, we present an algorithm for the safe postoperative treatment of patients with OSA without the use of CPAP or BiPAP. METHODS From January 2003 to December 2007, 1095 laparoscopic Roux-en-Y gastric bypasses were performed at our institution. Preoperative testing for OSA was not routinely performed. A prospective database was maintained. The data included patient demographics, co-morbidities (including OSA and CPAP/BiPAP use), perioperative events, complications, and follow-up information. Patients with known OSA were not given CPAP/BiPAP after surgery. They were observed in a monitored setting during their inpatient stay, ensuring continuous oxygen saturation of >92%. All patients used patient-controlled analgesia, were trained in the use of incentive spirometry, and ambulated within a few hours of surgery. The outcomes were compared between the OSA patients using preoperative CPAP/BiPAP versus those with OSA without preoperative CPAP/BiPAP versus patients with no history of OSA. RESULTS A total of 811 patients were included in the study group with no known history of OSA. Of the 284 patients with a confirmed diagnosis of OSA, 144 were CPAP/BiPAP dependent. Statistically significant differences were present in age distribution and gender, with men having greater CPAP/BiPAP dependency. No significant differences were found in body mass index, length of stay, pulmonary complications, or deaths. One pulmonary complication occurred in the OSA, CPAP/BiPAP-dependent group, three in the OSA, non-CPAP group, and six in the no-known OSA group. No anastomotic leaks or deaths occurred in the series. CONCLUSION Postoperative CPAP/BiPAP can be safely omitted in laparoscopic Roux-en-Y gastric bypass patients with known OSA, provided they are observed in a monitored setting and their pulmonary status is optimized by aggressive incentive spirometry and early ambulation.

Early jejunojejunostomy obstruction after laparoscopic gastric bypass: case series and treatment algorithm

BACKGROUND To review our experience with early jejunojejunostomy obstruction (JJO) at a large academic teaching hospital and provide a management algorithm. Early JJO is a known and often overlooked complication of laparoscopic Roux-en-Y gastric bypass. METHODS From 2003 to 2007, 1097 patients underwent laparoscopic Roux-en-Y gastric bypass at our institution. Data, including patient demographics, co-morbidities, intraoperative data, peri- and postoperative complications, and outcomes, were prospectively recorded and retrospectively reviewed. RESULTS Early post-laparoscopic Roux-en-Y gastric bypass JJO occurred in 13 patients (1.2%). The average time to presentation was 15 days (range 5-27). Patients presented with a combination of nausea, vomiting, and abdominal pain; all underwent computed tomography to confirm the diagnosis. The causes of JJO included dietary noncompliance (46%), anastomotic edema (23%), narrowing of the jejunojejunostomy at surgery (23%), and luminal clot (8%). Management was determined using our proposed treatment algorithm. Three patients (23%) required operative intervention, with the remainder successfully treated conservatively. CONCLUSION From our experience, we propose a treatment algorithm for standardized management of early JJO, reserving reoperation for those who are acutely ill on presentation or those in whom conservative management fails. A review of our series using this algorithm has suggested that most patients can be successfully treated nonoperatively; however, bariatric surgeons must maintain a low threshold for surgical re-intervention in cases in which rapid recovery is not seen.

Laparoscopic transgastric removal of eroded adjustable band: a novel approach

Gastric erosion is a well-known complication of laparoscopic adjustable gastric band (LAGB) placement for morbid obesity. We describe a novel approach for the removal of an eroded band through a laparoscopic gastrotomy with subsequent intraluminal division and removal of the band. A 67-year-old woman with a body mass index of 35.5 kg/m2 was seen 1 year after LAGB placement performed outside the United States. She had developed dysphagia and regurgitation of undigested food a few months after the procedure. The LAGB had been adjusted twice by her primary surgeons and was completely deflated once her symptoms began. The patient failed to improve and was subsequently referred to our institution where an upper endoscopy revealed intragastric band erosion. The patient was taken to the operating room for LAGB removal; however, standard laparoscopic and endoscopic attempts at band retrieval were unsuccessful. We then attempted a novel laparoscopic technique. An anterior gastrotomy was created, distal to the area of erosion, to facilitate easy intraluminal band division and removal. The gastrotomy was repaired, and a leak test was performed. A postoperative Gastrografin upper gastrointestinal series showed no extravasation. The patient began a diet, was discharged, and was seen in follow-up with complete resolution of her symptoms. The results of this case have shown that laparoscopic transgastric removal of an eroded gastric band is safe and feasible when standard endoscopic and laparoscopic techniques fail.

Laparoscopic repair of an internal strangulated supravesical hernia

We report the first case of bilateral temporomandibular joint (TMJ) dislocation in a woman after endoscopy. We go on to discuss the case reports published in the literature, with particular focus on potential factors that may predispose to this complication, and we offer some suggestions on dealing with this significant complication.

Laparoscopic Gastric Bypass in Patients on Thyroid Replacement Therapy for Subnormal Thyroid Function – Prevalence and Short-Term Outcome

Background: Hypothyroidism is associated with increased body weight. Weight gain may occur despite normal levels of serum thyroid stimulating hormone (TSH) and thyroxine (T4) achieved by replacement therapy. We evaluated the prevalence of patients on thyroid replacement for subnormal thyroid function who were operated on for morbid obesity and monitored their postoperative weight loss pattern. Methods: Data was identified from a prospectively accrued database of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) for morbid obesity from February 2000 to November 2001. All patients with subnormal thyroid function, diagnosed by past thyroid function tests and treated by an endocrinologist, who were on thyroid replacement therapy, were identified; 5 of these were matched for age, gender, preoperative body mass index (BMI) and surgical procedure (LRYGBP) to 5 non-hypothyroid patients. Weight loss at 3 and 9 months after surgery was compared between the 2 groups. Results: 192 patients underwent LRYGBP (n=155) or LAGB (n=37). Of the 21 patients (10.9%) on thyroid replacement identified, 14 were primary, 4 were postablative, and 3 were post-surgical; 17 underwent LRYGBP. All patients had normal preoperative serum levels of TSH and T4. Comparison of the 2 matched groups of patients revealed no difference in weight loss at 3 and 9 months after surgery (P=1.0). Conclusions: The prevalence of euthyroid patients on thyroid replacement for subnormal thyroid function who undergo surgical intervention for morbid obesity is high. Short-term weight loss in these patients is comparable to normal thyroid patients. Longer follow-up may be necessary to demonstrate the weight loss pattern in this group.

Patient behaviors associated with weight regain after laparoscopic gastric bypass

SUMMARY BACKGROUND Patients undergoing gastric bypass lose substantial weight, but 20% regain weight starting at 2 years after surgery. Our objective was to identify behavioral predictors of weight regain after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS We retrospectively surveyed 197 patients for factors predictive of weight regain (≥15% from lowest weight to weight at survey completion). Consecutive patients who had bariatric surgery from 1/2003 through 12/2008 were identified from an existing database. Response rate was 76%, with 150 patients completing the survey. RESULTS Follow-up after LRYGB was 45.0 ± 12.7 months, 22% of patients had weight regain. After controlling for age, gender, and follow-up time, factors associated with weight regain included low physical activity (odds ratio (OR) 6.92, P = 0.010), low self-esteem (OR 6.86, P = 0.008), and Eating Inventory Disinhibition (OR 1.30, P = 0.029). CONCLUSIONS Physical activity, self-esteem, and maladaptive eating may be associated with weight regain after LRYGB. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may identify patients at risk for weight regain who may benefit from tailored interventions.

Ruptured appendicitis after laparoscopic Roux-enY gastric bypass: pitfalls in diagnosing a surgical Abdomen in the morbidly obese.

A recent gastric bypass can mask the symptoms of an acute abdomen. Physical examination is generally unreliable and subtle clinical symptoms or signs should alert clinicians to a significant postoperative problem. In morbidly obese patients, the presence of overt peritoneal findings is usually ominous, leading to sepsis, organ failure and death. We report a case of ruptured appendicitis following a laparoscopic Roux-en-Y gastric bypass. The patient developed tachycardia, fever, and leukocytosis in the absence of abdominal pain or positive upper GI contrast studies. Eventually, a CT scan revealed a large pelvic abscess and inflammation. A subsequent exploratory laparotomy confirmed a perforated appendicitis with pelvic peritonitis. Her recovery was rapid and uneventful. This case highlights the pitfalls in promptly diagnosing an unrelated acute surgical abdomen postoperatively in the morbidly obese patient. The need for extreme vigilance and a low threshold for aggressive intervention in the period after bariatric surgery is emphasized.