David D. Kerrigan

Extended thromboprophylaxis reduces incidence of postoperative venous thromboembolism in laparoscopic bariatric surgery

BACKGROUND Venous thromboembolism (VTE) after laparoscopic bariatric surgery is a significant cause of morbidity and mortality. The objective of the present study was to study the incidence of symptomatic VTE in extended thromboprophylaxis regimens using dalteparin at an independent hospital in England, United Kingdom. METHODS A prospective database of all patients undergoing bariatric surgery was retrospectively analyzed. All patients underwent VTE prophylaxis regimen using perioperative and extended postoperative low-molecular-weight heparin (dalteparin 2500 IU preoperatively, followed by 5000 IU daily postoperatively). The treatment period was 1 week for laparoscopic gastric banding or 3 weeks for all other procedures. Inferior vena cava filters were used in selected patients with thrombophilia, a history of pulmonary embolism, or >1 episode of deep vein thrombosis. The endpoint was the incidence of symptomatic VTE. RESULTS A total of 735 patients underwent laparoscopic bariatric surgery, all of whom received dalteparin. The postoperative VTE incidence was 0%. The 30-day and 90-day all-cause mortality rate was 0%. A total of 3 adverse bleeding events occurred. CONCLUSION An extended VTE prophylaxis regimen using low-molecular-weight heparin is simple and effective and was associated with a low incidence of bleeding complications.

Obstructive sleep apnea can be safely managed in a level 2 critical care setting after laparoscopic bariatric surgery

BACKGROUND In the United Kingdom, demand for intensive care beds (level 3 critical care) often outstrips supply, leading to frequent and frustrating cancellation of complex elective surgery. It has been suggested that patients with obstructive sleep apnea who undergo bariatric surgery should be admitted to a level 3 facility for routine postoperative management. We have questioned the validity of this dogma in the era of laparoscopic bariatric surgery by using a simple easily applicable algorithm. OBJECTIVES The aim of this study was to investigate the clinical outcome of patients with obstructive sleep apnea (OSA) without admission to the intensive care unit after laparoscopic bariatric surgery. METHODS For the first 24 hours after surgery, all patients were admitted to a level 2 (high-dependency) area on a general surgical ward with experience of bariatric surgery. They received supplemental oxygen, continuous pulse oximetry, and judicious analgesic administration using a combination of small boluses of i.v. morphine together with i.v. paracetamol. Perioperative continuous positive airway pressure support was not routinely given, unless patients with OSA had oxygen saturation below their recorded preoperative level on 2 consecutive readings. RESULTS A total of 1623 patients underwent laparoscopic bariatric surgery over a 12-year period. Of those, 192 had OSA with a median operative body mass index of 52 kg/m(2) (range 34-78 kg/m(2)). The incidence of respiratory complications and the median length of stay (3 nights) were identical in patients with OSA and those without OSA. Four patients self-administered perioperative continuous positive airway pressure, but none required transfer to intensive care or mechanical ventilation. There were no in-hospital deaths. CONCLUSION Laparoscopic bariatric surgery in patients with OSA is well tolerated and does not require the routine use of level 3 critical care facilities.

Petersen hernia complicating laparoscopic duodenal switch

l p t b Petersen type hernias have become increasingly recognized with the worldwide adoption of laparoscopic gastric bypass. So-called Petersen’s hernia (PH) is contemporarily defined as an internal hernia through the space between the mesentery of the alimentary limb and the transverse mesocolon. PH can be classified by type and symptoms [1]. No level I data are available to inform surgeons whether Petersen’s space should be closed at primary surgery, and this has led to a lively debate in published studies [2–6]. However, it is clear that PH can present nonspecifically, is diagnostically challenging, and can rapidly cause fatal complications. Our unit policy is to close Petersen’s space at gastric bypass. Similar to gastric bypass, Petersen’s space is created during laparoscopic biliopancreatic diversion and duodenal switch (BPD/DS) procedure (Fig. 1). A paucity of data is available regarding PH and laparoscopic BPD/DS. We present 4 cases of symptomatic PH complicating laparoscopic BPD/DS (Table 1).

Petersen's hernia after laparoscopic Roux-en-Y gastric bypass— case report, diagnostic sign, and proposed classification system

The adoption of laparoscopic Roux-en-Y gastric bypass(LRYGB) has been driven by clear benefits compared withthe open procedure, including fewer perioperative compli-cations, a shorter hospital stay, and more rapid recovery[1,2]. Moreover, the weight loss outcomes have been similarto those achieved with the open approach [2].A growing body of data has identified that these benefitsmight be offset by an increased incidence of internal herniasafter LRYGB [3]. One particular type of internal hernia isthe so-called Petersen’s hernia. This refers to a herniathrough the space between the Roux limb of the LRYGBand the transverse mesocolon. The true incidence of thishernia is unknown, although large case series have sug-gested that it might occur in 0–18% of cases [3–6]. How-ever, this might be influenced by the surgical technique,such as the orientation of the cut end of the Roux limb [7]and closure of mesenteric defects [8,9].The presentation of this type of internal hernia can benonspecific, and a delay in the diagnosis and appropriatetreatment can be fatal. Imaging modalities such as computedtomography can provide useful diagnostic information, butthe interpretation can be challenging [10].We present a case of incarcerated Petersen’s hernia as-sociated with a novel diagnostic sign. In addition, we pro-pose a classification system that might improve the auditand outcomes of this potentially fatal complication.

Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD-DS) Surgery

Biliopancreatic diversion with duodenal switch (BPD-DS) produces unmatched weight loss and superb resolution of comorbidities, particularly type 2 diabetes; however BPD-DS remains a controversial procedure that polarises opinion in both surgeons and patients. It combines surgical bypass of the majority of the small intestine with a sleeve gastrectomy in an attempt to produce greater weight loss and improved remission of comorbidities compared to that seen after Roux-en-Y gastric bypass (RYGB), whilst reducing the incidence of common side effects of a standard BPD such as marginal ulceration and dumping syndrome. With careful patient selection, meticulous technique and attentive follow-up, BPD-DS offers patients outstanding long-term clinical results, a surprisingly good quality of life and an effective revisional option when other procedures have failed. Done badly, it is a recipe for protein-calorie malabsorption and a return to the bad old days of bariatric surgery from the 1970s. In this chapter we explore the essentials of how to use this powerful tool- the nuclear option in the bariatric surgeon’s armamentarium- safely and effectively.

Evidence Base for Bariatric Surgery

Bariatric surgery is recognized worldwide as a cost-effective treatment for morbidly obese patients. In recent years, the role of these procedures has been revised following the impressive postoperative outcomes from a metabolic and functional viewpoint. These outcomes have given rise to further possible indications for bariatric procedures that could be applied to non-obese patients in the near future. This chapter summarizes the evidence collected following bariatric procedures, both in terms of weight loss and remission of co-morbidities. We still need to clarify the concepts of “ideal weight” and “success” in bariatric surgery and moreover the exact interaction between gut hormones, pancreatic endocrine function and adipose cell signaling needs further investigations to predict a possible outcome or a possible relapse of a metabolic condition.

The safety and transformative power of bariatric surgery

Bariatric surgeons realise that the zeal for performing what we see as life transforming surgery is not shared outside the specialty. Non-surgeons often perceive such operations as “drastic” or “barbaric.” The BMJ ’s choice of a blood and …

Metabolic surgery may be more effective

The LOADD study1 did not consider a more effective form of nutritional intervention—metabolic (bariatric) surgery—which is a proved treatment for obesity and type 2 diabetes.2 In a study of people with type 2 diabetes randomised to laparoscopic gastric banding or best medical treatment, banding was associated with greater total …