Fernando Bonanni

Gastroesophageal Reflux Symptoms After Laparoscopic Sleeve Gastrectomy for Morbid Obesity. The Importance of Preoperative Evaluation and Selection.

Background: Gastroesophageal reflux disease (GERD) is prevalent in morbidly obese patients, and its severity appears to correlate with body mass index (BMI). Aim: The aim of this study is to investigate the status of GERD after laparoscopic sleeve gastrectomy (LSG). Materials and Methods: A prospectively maintained database of all the patients who underwent LSG from February 2008 to May 2011 was reviewed. Results: A total of 131 patients were included. The mean age and the BMI of the patients were 49.4 years and 48.9 kg/m 2 , respectively. Prior to LSG, subjective reflux symptoms were reported in 67 (51%) patients. Anatomical presence of hiatal hernia was endoscopically confirmed in 35 (52%) patients who reported reflux symptoms prior to LSG. All these patients underwent simultaneous hiatal hernia repair during their LSG. The overall mean operative time was 106 min (range: 48-212 min). There were no intra- and 30-day postoperative complications. Out of the 67 preoperative reflux patients, 32 (47.7%) reported resolution of their symptoms after the operation, 20 (29.9%) reported clinical improvement, and 12 (22.2%) reported unchanged or persistent symptoms. Three patients developed new-onset reflux symptoms, which were easily controlled with proton pump inhibitors. No patient required conversion to gastric bypass or duodenal switch because of the severe reflux symptoms. At 18 months, the follow-up data were available in 60% of the total patients. Conclusion: LSG results in resolution or improvement of the reflux symptoms in a large number of patients. Proper patient selection, complete preoperative evaluation to identify the presence of hiatal hernia, and good surgical techniques are the keys to achieve optimal outcomes.

Is laparoscopic single-stage biliopancreatic diversion with duodenal switch safe in super morbidly obese patients?

BACKGROUND It has been hypothesized that the morbidity and mortality of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) are likely to increase with increasing body mass index (BMI), especially with BMI>50 kg/m(2). Therefore, a 2-stage approach to this procedure has been advocated in super morbidly obese patients. The authors hypothesized that a BMI ≥ 50 kg/m(2) does not significantly influence the morbidity and mortality perioperatively associated with this procedure. METHODS A retrospective analysis of all patients who underwent laparoscopic BPD-DS between January 2009 and September 2011 was performed. The patients were divided into 2 groups: patients with BMI<50 kg/m(2) and those with BMI>50 kg/m(2). Patient characteristics, perioperative variables, 30-day outcomes, and complications were analyzed and compared. RESULTS A total of 226 patients underwent laparoscopic BPD-DS. Mean patient age was 44.9 years (range: 20-72 yr). Male to female ratio was 59 to 170 patients (75% versus 25%), respectively. Mean BMI was 50.2 kg/m(2) (range: 37.2-68.8 kg/m(2)). A total of 127 patients had a BMI<50 kg/m(2) (Group 1), and 99 patients had a BMI ≥ 50 kg/m(2) (Group 2). The length of procedure in Groups 1 and 2 was 296 minutes and 287 minutes, respectively (P = .25). The rate of conversion to open BPD-DS was 1.5% in Group 1 and 3% in Group 2 (P = .65). Two leaks occurred in Group 1; no patient in Group 2 developed this complication. One patient in Group 2 developed pulmonary embolism. The rates of all other complications resulting in a longer length of stay were 11% in Group 1 and 8% in Group 2 (P = .50). The 30-day reoperation rate was 3% in Group 1 and 1% in Group 2 (P = .39). The mean length of stay was 3.97 days for Group 1 and 3.67 days for Group 2 (P = .34). No mortality occurred in this series. CONCLUSION In the present study, BMI ≥ 50 kg/m(2) did not increase intraoperative or postoperative complications at 30 days after laparoscopic PBD-DS. No significant differences were noted between patients with BMI ≥ 50 kg/m(2) and patients with BMI<50 kg/m(2). A single-stage laparoscopic BPD-DS procedure can be safely offered to the super morbidly obese patients.

Outcome analysis of early laparoscopic sleeve gastrectomy experience.

This report suggests that laparoscopic sleeve gastrectomy is safe and effective as a definitive bariatric procedure.

Normoglycemic ketoacidosis in a postoperative gastric bypass patient taking canagliflozin

Normoglycemic ketoacidosis in a postoperative gastric bypass patient taking canagliflozin Fernando B. Bonanni, M.D., F.A.C.S., F.A.S.M.B.S., Patrick Fei, M.D.*, Laura L. Fitzpatrick, M.D., M.P.H. Department of Surgery, Institute for Metabolic and Bariatric Surgery, Abington Memorial Hospital, Abington, Pennsylvania Department of Medicine, Endocrinology Division, Abington Memorial Hospital, Abington, Pennsylvania Received July 2, 2015; accepted August 14, 2015

Venous thromboembolism after laparoscopic biliopancreatic diversion with duodenal switch: Analysis of 362 patients

BACKGROUND Venous thromboembolism (VTE), which manifests as deep venous thrombosis (DVT) or pulmonary embolism (PE), is relatively uncommon after weight loss procedures but has the strong potential to affect patient morbidity and mortality. This type of complication has been studied extensively in more common weight loss procedures, such as Roux-en-Y gastric bypass (RYGB). VTE has not been studied after biliopancreatic diversion with duodenal switch (BPD-DS), a bariatric procedure performed mainly for super morbidly obese patients, who are inherently associated with a higher incidence of co-morbidity. The objective of this study was to review VTE prevalence and identify risk factors associated with the postoperative occurrence of VTE in a collected data set of patients after laparoscopic BPD-DS. METHODS The database of all patients who underwent laparoscopic BPD-DS between 2006 and 2012 was reviewed. Preoperative clinical information, which included history of VTE, inferior vena cava (IVC) filter placement, operative variables, and postoperative course, were reviewed. All VTE related events that occurred within 90 days postoperatively were collected and analyzed. RESULTS Of 362 patients who underwent laparoscopic BPD-DS during the study period, 12 (3.3%) experienced a VTE complication. Eight (2.2%) patients presented with DVT; 4 (1.1%) patients presented with PE. VTE complications were more common in females than males (83.3% versus 16.6%, respectively). Age, body mass index (BMI), and time interval between preoperative and postoperative doses of heparin for DVT prophylaxis did not influence the occurrence of VTE complications. However, operative time (P = .02) and length of hospital stay (P = .0005) were identified as risk factors associated with postoperative VTE complications. No related mortality occurred in this study. CONCLUSION The prevalence of VTE after BPD-DS is relatively low and comparable to other weight loss procedures. Overall risk of postoperative VTE after laparoscopic BPD-DS appears to be associated with the length of operation and hospital stay.

Comparison of vertical sleeve gastrectomy versus biliopancreatic diversion.

Background: Vertical sleeve gastrectomy (VSG) was originally performed as the first-stage of biliopancreatic diversion with duodenal switch (BPD/DS) for superobesity as a strategy to reduce perioperative complications and morbidity. VSG is now considered a definitive procedure because of its technical simplicity and promising outcomes. Aims: To analyze the outcomes of laparoscopic VSG and to compare them with those of single-stage laparoscopic BPD/DS. Materials and Methods: A retrospective review of 200 consecutive patients who underwent VSG and BPD/DS between 2008 and 2011. Results: A total of 100 patients underwent laparoscopic VSG and 100 patients underwent laparoscopic BPD/DS. The patients in VSG group were older, but gender distribution and body mass index were comparable. Mean operative time for VSG was significantly shorter compared with that of BPD/DS. A single patient in each groups required open conversion. Staple line leak (n = 1) and intraluminal hemorrhage into the newly-created sleeve (n = 1) occurred in the BPD/DS group. Mean length of stay was shorter after VSG (3.1 vs. 3.9 days). At 6 months postoperatively, excess weight loss between the two groups revealed statistically significant difference, favoring BPD/DS. Conclusions: Despite promising outcomes and technical simplicity of VSG, BPD/DS provides significantly superior excess weight loss in morbidly obese patients.

Conversion of failed Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch: outcomes of 9 case series

INTRODUCTION Weight regain after Roux-en-Y gastric bypass (RYGB) is a frustrating long-term complication in some patients. Revision of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS) is an appealing option. There is a paucity of information in literature regarding this type of conversion. SETTING Regional referral center and teaching hospital, Pennsylvania, United States; nonprofit. METHODS Between 2013 and 2016, a retrospective chart review was performed on all our revision cases. Patients who underwent conversion from RYGB to BPD-DS were selected and analyzed. RESULTS Conversion from RYGB to BPD-DS was performed on 9 patients (8 females, 1 male; mean age: 49.2±7.6 [36-61] years). The mean body mass index (BMI) before the initial RYGB was 54.2±14.2 (36.2-79) kg/m2. The lowest mean BMI reached before conversion was 33.9±6.2 (27.9-43.3) kg/m2 before it increased to 45.6±8.7 (28.8-60.2) corresponding to excess weight loss (EWL) of 33.1%±17.7% (10.6%-68.1%), before conversion. The average operative time was 402.6±65.8 (328-515) minutes for 1-stage conversions. No morbidities, reoperation, or readmission over 30 days postoperatively were reported. No leaks or mortalities were identified. The mean duration of follow-up postconversion is 16.3±13.6 (3-42) months. After conversion surgery, the mean BMI was 35.8±8.2 (27.6-49.5) kg/m2, while mean EWL loss was 64.1%±18.8% (45.9%-88.7%). The BMI of the cohort decreased by a mean of 9.8±5.1 (0.5-16.8) and the EWL increased by 31%±23.1% (4%-76.6%). CONCLUSION Our results indicate that conversion of failed RYGB to BPD-DS is laparoscopically or robotically safe and effective. A large cohort study with long-term follow-up is necessary to further assess the safety and efficacy of this method.

How to Switch to the Switch: Implementation of Biliopancreatic Diversion with Duodenal Switch into Practice

The biliopancreatic diversion with duodenal switch (BPD/DS), a modification of the classic Scopinaro procedure, carries the highest rate of success in terms of weight loss, comorbid resolution, and maintenance of weight loss. The substantial challenges, technical complexity, and expected roadblocks of adding BPD/DS option to the bariatric surgeon’s resources are reflected in the number of BPD/DS procedure performed in the USA, being less than 1% of all bariatric surgeries. Adjustments to the length of the common channel and the size of the vertical sleeve would increase the pool of candidates for BPD/DS and offer comprehensive management of obesity and metabolic comorbidities. Proper educational programs and multiple proctoring to bariatric surgeons aid to implement BPD/DS to their practice.

Asymptomatic gastric remnant leak after laparoscopic Roux-en-Y gastric bypass

w c r v b c n i t U r s w r p h f w Anastomotic leaks complicate .8 –7% of Roux-en-Y astric bypass (RYGB) procedures and are recognized as he most common preventable cause of death after pulonary embolism [1]. The 2 traditional tools used to etect anastomotic leaks are drains and upper gastroinestinal studies. However, increasing experience and delining leak rates have led many bariatric surgeons to bandon the routine use of drains and upper gastrointesinal studies to detect leaks, in favor of clinical signs, a ow threshold for reoperation, and surgeon discretion egarding the placement of drains [2,3]. We present the case of a 42-year-old man who had ndergone an uneventful laparoscopic RYGB (i.e., no disretionary reason to place a drain and no clinical reason to eoperate), whose potentially devastating gastric remnant eak was diagnosed only because the fluid in his Jacksonratt (JP) drain changed from serosanguinous to brown, and nalysis of the fluid revealed an amylase level of 10,114 /L. To our knowledge, although completely asymptomatic astrojejunostomy (GJ) leaks have been reported, this is the rst reported case of a completely asymptomatic gastric emnant leak. This is an important distinction because, alhough GJ leaks can heal on their own, gastric remnant leaks re typically high-volume leaks that can lead to rapid deteioration of the patient [1]. Gastric remnant leaks are also eaks whose presentation can be delayed, undermining the bility of clinical parameters to detect them. Therefore, we elieve our case supplies the first actual example of a otentially devastating asymptomatic gastric remnant leak

Venous thromboembolism after laparoscopic or robotic biliopancreatic diversion with duodenal switch. Ninety-days outcome of a 10 years’ experience

BACKGROUND Venous thromboembolism (VTE) is a feared complication after bariatric surgery. Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex bariatric procedure that is offered typically to super morbidly obese patients. Scarce data exist in reporting VTE outcome and identifying the risk factors associated with it after BPD-DS. OBJECTIVE To determine the risk factors for VTE after BPD-DS at 90-day follow-up. SETTING A nonprofit regional referral center and teaching hospital in Pennsylvania. METHODS A retrospective chart review was performed on prospectively collected data over 10 years, between January 1, 2006 and December 31, 2016. Patients who underwent laparoscopic or robotic BPD-DS were included. Preoperative variables, selected risk factors, and methods of VTE prophylaxis were analyzed. RESULTS A total of 662 patients who underwent BPD-DS were identified. The mean age was 44.7 ± 10.4 (20-72) years; 474 patients were female (71.7%), and the mean body mass index of the cohort was 50.5 ± 7.5 (34-98) kg/m2. Overall, 16 patients (2.4%) experienced VTE complication at 90-days follow-up post-BPD-DS with 100% follow-up rate; deep vein thrombosis was experienced by 10 patients (1.5%), and 6 patients (0.9%) experienced pulmonary embolism (1 patient experience both). None of those patients had a previous history of VTE. Only operative time (P value = .009) and length of stay (P value ≤ .001) were associated with VTE events. Other factors such as age, sex, body mass index, previous history of VTE, preoperative heparin injection, preoperative inferior vena cava filter insertion, intermittent compressive device use, interval heparin time, and postoperative chemical prophylaxis did not show a statistical association. A logistic regression analysis showed a statistically significant increase of VTE outcome with length of stay; odds ratio of 1.161, (95% confidence interval, 1.048-1.285), P value = .004. CONCLUSION With proper preoperative evaluation and aggressive VTE prophylaxis protocol, the risk of VTE post-BPD-DS is comparable to other bariatric procedures. Every effort should be adopted to shorten the length of stay, and thus reduce VTE risk.