Craig A. Ternovits

Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass

Background: Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. Results: Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B12 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. Conclusions: Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

BackgroundThe utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.MethodsAll patients who underwent LRYGB at the authors’ institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.ResultsThis study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).ConclusionsAccording to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.

Laparoscopic Revision of the Gastrojejunostomy for Recurrent Bleeding Ulcers after Past Open Revision Gastric Bypass

Late complications of open gastric bypass can include malnutrition, weight gain, stomal stenosis, and recurrent bleeding ulcers. Herein, we describe the case of a woman who had recurrent bleeding ulcers, after an open revision of a stenotic gastric bypass. She now underwent an uneventful laparoscopic revision of her gastrojejunostomy and was discharged within 72 hours. Laparoscopic revision of a gastrojejunostomy, even after an open revision following an open gastric bypass, can be done safely.

Laparoscopic Roux-en-Y Gastric Bypass with Subtotal Gastrectomy

Laparoscopic gastric bypass is a common procedure for morbid obesity. After gastric bypass, the distal stomach is unavailable for surveillance. When a suspicious distal gastric lesion is present preoperatively, a distal subtotal gastrectomy may be needed. Herein we describe such a case performed laparoscopically. Laparoscopic gastric bypass with subtotal gastrectomy for morbid obesity should be considered for patients with suspicious distal gastric lesions.

Does Laparoscopic Gastric Bypass Result in a Healthier Body Composition? An Affirmative Answer

Background: Bariatric surgery results in sustained weight loss. While weight loss is the goal of bariatric surgery, fat loss and muscle conservation are germaine goals. This study investigated the hypothesis that body composition would significantly change after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Patients undergoing LRYGBP were studied. Percent fat and percent water were calculated via bioelectrical impedance analysis (BIA). Waist and hip circumference were measured in all patients as well. Measurements were taken preoperatively, and at 1 month, 3 months, 6 months, and 1 year. Non-parametric ANOVA was utilized for statistical analysis. Results: There were 151 patients included in this study. Fat percentage (48.6 ± 10.0 vs 34.6 ± 10.8; P<0.001), total fat mass (141 ± 37 vs 67 ± 30; P<0.0001) and total water mass (108 ± 27 vs 93 ± 23; P<0.0001) decreased postoperatively at 1 year. Water percentage increased postoperatively at 1 year (37.0 ± 6.6 vs 52.5 ± 3.3; P<0.001). Waist:hip ratio improved from preoperatively to 1 year postoperatively (0.895 ± 0.115 vs 0.811 ± 0.076; P<0.001). Conclusions: Bariatric surgery results not only in fat loss but also in a change in body composition. Improved waist:hip ratio, fat percentage decreases, and water percentage increases all indicate an overall healthy body composition. While weight loss is important, improvement in body composition should be another recognized benefit of bariatric surgery.

Inpatient pain medication requirements after laparoscopic gastric bypass

Introduction: One of the benefits of laparoscopic Roux-en-Y gastric bypass (RYGBP) includes decreased pain, possibly resulting in decreased narcotic use, quicker recovery of bowel function, and shorter hospital stay. We utilize a pain management strategy for our patients undergoing laparoscopic RYGBP. We investigated this strategy as well as narcotic use and incidence of ileus. Methods: Inpatient data for patients who underwent laparoscopic RYGBP were collected. Our pain management strategy included a standing dose of ketorolac, morphine sulphate as needed, and propoxyphene hydrochloride/acetaminophen as needed after liquids were initiated. No PCAs were utilized. Results: There were 104 patients in this study. 12 patients did not undergo our pain management strategy due to reoperation (5), postoperative hemorrhage (2), and allergies (5). 2 patients required no pain medications other than ketorolac. Only 2 patients had a delay of discharge (postoperative day [POD] 3 and 5) due to lack of bowel function. An average of 11.2 mg of morphine and an average of 170 mg of propoxyphene (1.7 pills) were given by the end of POD 2. In addition, 74% of patients required no morphine on POD 2 and 48% of patients required no propoxyphene on POD 2. Bowel movements were reported in 65% patients on POD 1. Conclusions: After laparoscopic RYGBP, only a minimal amount of narcotic use is necessary. Few patients have an ileus when utilizing this pain management strategy after laparoscopic RYGBP.

Preoperative carbohydrate Addiction does not predict weight loss after laparoscopic gastric bypass

Background: Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass. Methods: 104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients. Results: Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36±13 vs 33±15; P=NS). Conclusions: Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.

Why Would Laparoscopic Gastric Bypass Patients Choose Open Instead

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be comparable to open Roux-en-Y gastric bypass (ORYGBP) surgery in randomized studies. Although a steep learning curve exists, laparoscopic bariatric surgery offers advantages if performed by an experienced bariatric surgeon. Despite these facts, some patients still choose to undergo ORYGBP. This investigation explored the reasons why patients who have had LRYGBP would decide to undergo the laparoscopic operation. Methods: A survey was given to patients who had undergone LRYGBP. The survey was designed to ascertain what factors would influence them to have LRYGBP versus ORYGBP. Incomplete responses were not included in the data analysis. Results: There were 41 patients who filled out the survey. Over 90% of the patients felt LRYGBP is better than open gastric bypass. There were 4 patients who had seen another surgeon who recommended ORYGBP. Approximately 61% (23/38) of the patients would have stayed with their surgeon even if their surgeon did not offer LRYGBP. In addition, 79% of patients (31/39) would have ORYGBP if their insurance did not cover LRYGBP. Most patients (67%) would have ORYGBP if their surgeon thought LRYGBP was experimental. If they were told that LRYGBP was too risky for them, 77% of patients (30/39) would have undergone ORYGBP. Only 15% of patients (6/40) would not have had surgery if LRYGBP did not exist. Conclusions: Patients are willing to undergo ORYGBP even if they believe that LRYGBP is better. Non-medical factors and/or surgeon recommendations instead of scientific data influence patient decision-making when choosing ORYGBP over LRYGBP.

Laparoscopic Removal of Gastric Band after Open Banded Gastric Bypass

Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials) around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical expertise is available.