Andrew T. Strong

Adjustments to warfarin dosing after gastric bypass and sleeve gastrectomy

BACKGROUND Warfarin dosing after bariatric surgery may be influenced by alterations in gastrointestinal pH, transit time, absorptive surface area, gut microbiota, food intake, and adipose tissue. OBJECTIVES The aim of this study was to describe trends in warfarin dosing after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING Single academic center. METHODS All patients chronically on warfarin anticoagulation before RYGB or SG were retrospectively identified. Indications for anticoagulation, history of bleeding or thrombotic events, perioperative complications, and warfarin dosing were collected. RESULTS Fifty-three patients (RYGB n = 31, SG n = 22) on chronic warfarin therapy were identified (56.6% female, mean 54.4 ± 11.7 yr of age). Of this cohort, 34.0% had prior venous thromboembolic events, 43.4% had atrial fibrillation, and 5.7% had mechanical cardiac valves. Preoperatively, the average daily dose of warfarin was similar in the RYGB group (8.3 ± 4.1 mg) and SG group (6.9 ± 2.8 mg). One month after surgery, mean daily dose of warfarin was reduced 24.1% in the RYGB group (P<.001) and 23.2% in the SG group (P = .002). At 12 months postoperatively, the required daily warfarin dose compared with baseline remained statistically different (RYGB: 6.8 ± 3.8 mg; SG: 6.1 ± 2.0 mg). CONCLUSIONS The warfarin dose is expected to be decreased by approximately 25% from preoperative levels after both RYGB and SG. Lower dose requirement within the first month after bariatric surgery is followed by a trend toward increased warfarin dose requirements, but remain less than baseline. Because dose requirements change constantly over time, frequent postoperative monitoring of the international normalized ratio is recommended.

How I Do It: Per-Oral Pyloromyotomy (POP)

IntroductionSeveral surgical treatments exist for treatment of gastroparesis, including gastric electrical stimulation, pyloroplasty, and gastrectomy. Division of the pylorus by means of endoscopy, Per-Oral Pyloromyotomy (POP), is a newer, endoluminal therapy that may offer a less invasive, interventional treatment option.MethodsWe describe and present a video of our step by step technique for POP using a lesser curvature approach. The following are technical steps to complete the POP procedure from the lesser curve approach.ConclusionIn our experience, these methods provide promising initial results with low operative risks, although long-term outcomes remain to be determined.

Common Bile Duct Dilation after Bariatric Surgery

Background Biliary dilation suggests obstruction and prompts further work up. Our experience with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in the symptomatic post-bariatric surgery population revealed many patients with radiographically dilated bile ducts, but endoscopically normal studies. It is unclear if this finding is phenomenological or an effect of surgery. Additionally, it is unknown whether the type of bariatric surgery alters biliary pathophysiology. Thus, we studied whether a change occurs in biliary diameter following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

Feeding the gut after revisional bariatric surgery: The fate of 126 enteral access tubes

BACKGROUND Revisional bariatric surgery (RBS) is associated with higher complication rates compared with primary bariatric surgery. Feeding tubes (FTs), including gastrostomy and jejunostomy tubes placed during RBS, may serve as a safety net to provide nutrition when oral intake is contraindicated or limited; however, FTs in this setting have not been well investigated. OBJECTIVES This study aims to determine complications, use, and duration of FTs placed during RBS. SETTING A high-volume academic medical center in the United States. METHODS Included patients underwent RBS between January 2008 and December 2016 with FTs placed at the time of RBS. RESULTS There were 126 patients identified (84.9% female, 76.2% Caucasian, mean age 53.4-±10.9 yr). Patients had previously undergone Roux-en-Y gastric bypass (34.1%), vertical banded gastroplasty (27.8%), and adjustable gastric band (14.3%). Indications for RBS included correction of complication of prior bariatric surgeries (50%), weight regain/failure to lose weight (32.3%), or both (17.3%). Most FTs were placed in the excluded stomach (89.7%), and median tube size was 18 F. FTs were used for feeding in 68.2% of patients, with feeding initiated in a median of 2 days. Leakage around the tube (32.5%) and pain (26.8%) were common complaints. Significant tube-related complications included infection (9.1%), dislodgement (5.9%), reintervention (5.8%), and reoperation (2.8%); 16.7% experienced at least 1 significant complication. FTs were removed at a median of 36 days. CONCLUSION FTs may aid in prevention of perioperative dehydration and malnutrition after RBS, but should not be considered a benign intervention. FT use should be balanced against institutional outcomes and care goals.

Conversion and Revisional Surgery: Sleeve Gastrectomy

Sleeve gastrectomy (SG) was initially conceived as a component of a biliopancreatic diversion and duodenal switch operation. Later, noting significant weight loss with the gastric sleeve alone, the paradigm shifted toward SG as the first stage of a two-stage biliopancreatic diversion and duodenal switch and eventually gained significant popularity as a stand-alone bariatric operation. Thus SG has always been a revisable procedure. Numerous indications for revision of a prior SG exist, with an equal number of possible operative conversion. Generally SG revisional surgery addresses complications of a SG, most notably either staple-line leak or stenosis, mechanical issues related to sleeve construction, and development of treatments of new comorbid conditions, failure to lose weight, or weight recidivism. In other cases SG revision is pre-planned as a second operation in patients with super-morbid obesity. Consideration of the indication for revision commonly directs the surgeon to the most reasonable revisional operation.

Conversion and Revisional Surgery: Roux-en-Y Gastric Bypass

Gastric bypass has proven to be an effective operation in terms of both weight loss and resolution of comorbid conditions. However a subset of patients will require revision for complications and technical mishaps incurred at the index operation. In other patients, gastric bypass will fail to produce adequate weight loss or will have weight regain. In some this will lead to recurrence or development of de novo comorbid conditions. These patients may also benefit from revisional operations.

Effect of Surgical Weight Loss on Plantar Fasciitis and Healthcare Utilization

BACKGROUND: Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF. METHODS: A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type. RESULTS: Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 ( P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 ( P = .01). CONCLUSIONS: We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.

Completion Gastrectomy with Esophagojejunostomy for Management of Complications of Benign Foregut Surgery

BACKGROUND With the worldwide epidemic of obesity, an increasing number of bariatric operations and antireflux fundoplications are being performed. Despite low morbidity of the primary foregut surgery, completion gastrectomy may be necessary as a definitive procedure for complications of prior foregut surgery; however, the literature evaluating outcomes after completion gastrectomy with esophagojejunostomy (EJ) for benign diseases is limited. We present our experience of completion gastrectomy with Roux-en-Y EJ in the setting of benign disease at a single tertiary center. METHODS AND PROCEDURES All patients who underwent total, proximal, or completion gastrectomy with EJ for complications of benign foregut surgery from January 2006 to December 2015 were retrospectively identified. All cancer operations were excluded. RESULTS There were 23 patients who underwent gastrectomy with EJ (13 laparoscopic EJ [LEJ] and 10 open EJ). The index operations included 12 antireflux, 9 bariatric, and 2 peptic ulcer disease surgeries. Seventy-eight percent of patients had surgical or endoscopic interventions before EJ, with a median of one prior intervention and a median interval from the index operation to EJ of 25 months (interquartile range 9-87). The 30-day perioperative complication rate was 30% with 17% classified being major (Clavien-Dindo ≥ III) and no 30-day perioperative mortality. Comparing laparoscopic and open approaches showed similar operative times, estimated blood loss, and overall complication rate. LEJ was associated with a shorter length of stay (LOS) (P < .001), fewer postoperative ICU days (P = .002), fewer 6-month complication rates (P < .007), and decreased readmission rate (P = .024). CONCLUSION Our series demonstrates that EJ is a reasonable option for reoperative foregut surgery. The laparoscopic approach appears to be associated with decreased LOS and readmissions.

Optimal injection solution for endoscopic submucosal dissection: A randomized controlled trial of Western solutions in a porcine model

When carrying out endoscopic submucosal dissection (ESD), procedural safety increases with greater tissue elevation and efficiency increases with longer‐lasting submucosal cushion. Fluids specifically developed for ESD in Asia are not commercially available in the West, leaving endoscopists to use a variety of injectable fluids off‐label. To determine the optimal fluid available in the West, we compared commonly used fluids for Western ESD.

Hernia repair in patients with chronic liver disease - A 15-year single-center experience

BACKGROUND Elective hernia repairs in chronic liver disease (CLD) patients are often avoided due to the fear of hepatic decompensation and mortality, leaving the patient susceptible to an emergent presentation. METHODS CLD patients undergoing ventral or inguinal hernia repair in emergent and non-emergent settings at our institution (2001-2015) were analyzed. Predictors of 30-day morbidity and mortality (M&M) were determined using univariate analysis and multivariate logistic regression. RESULTS A total of 186 non-emergent repairs identified acceptable rates of M&M (27%) and 90-day mortality (3.7%, 0/21 for MELD≥15). Meanwhile, 67 emergent repairs had higher rates of M&M (60%) and 90-day mortality (10%; 25% for MELD≥15). M&M was associated with elevated MELD scores in emergent cases (14 ± 6 vs 11 ± 4; p = 0.01) and intraoperative drain placement in non-emergent cases (OR1.31,p < 0.01). CONCLUSION In patients with advanced CLD, non-emergent hernia repairs carry acceptable rates of M&M, while emergent repairs have increased M&M rates associated with higher MELD scores.