Gautam Sharma

Incidence and Clinical Features of Diabetic Ketoacidosis After Bariatric and Metabolic Surgery

Bariatric surgery is considered an effective (1,2) and relatively safe (3) option for the treatment of obesity and its comorbidities, including type 1 and type 2 diabetes. Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes, which mainly occurs in patients with type 1 diabetes but can present in patients with type 2 diabetes under stressful conditions (4,5). The characteristics of early postoperative DKA following bariatric surgery are largely unknown. The objective of this study is to determine the incidence and clinical circumstances underlying DKA after bariatric surgery. From January 2005 to December 2015, a total of 12 patients who developed DKA within 90 days following bariatric surgery at an academic center were identified in a database approved by an institutional review board. All patients met the American Diabetes Association criteria for the diagnosis of DKA (4,5). Two endocrinologists independently verified the diagnosis of DKA in the included patients. Baseline characteristics, intraoperative data, and postoperative outcomes were assessed. Of the 12 patients who developed …

Endoscopic stents in the management of anastomotic complications after foregut surgery: new applications and techniques

BACKGROUND Anastomotic complications after foregut surgery include leaks, fistulas, and late strictures. The management of these complications can be challenging, and it may be desirable to avoid complex reoperation. OBJECTIVES We aim to describe the indications and outcomes of the use of esophageal self-expanding metal stents in the management of postoperative anastomotic complications after foregut surgery. SETTING Tertiary-referral academic medical center. METHODS We performed a retrospective review of a prospectively managed database. Data was collected on patient demographic characteristics, work-up, intraprocedure findings, and outcomes. RESULTS From October of 2009 to November of 2014, 47 patients (mean age 51.1, 36 women and 11 men) underwent endoscopic stent placement for anastomotic complications following upper gastrointestinal (UGI) surgery. The median time from index operation to endoscopic stent placement was 52 days (range 1-5280 days). Indications were sleeve leak or stenosis, gastrojejunal leak or stenosis after Roux-en-Y gastric bypass (RYGB), pouch staple-line leak after RYGB, enterocutaneous fistula, perforation after endoscopic dilation, upper gastrointestinal bleeding after peroral endoscopic myotomy (POEM), and peptic stricture after POEM. Symptomatic improvement occurred in 76.6% of patients, and early oral intake was initiated in 66% of patients. 14 patients (29.8%) went on to require definitive surgical intervention for persistent symptomatology. The average follow-up was 354.1 days (range 25-1912 days). CONCLUSION This paper describes the use of endoscopic stent therapy for a variety of pathologies after upper gastrointestinal surgery. We demonstrate that, in the appropriate setting, it is an effective and less-invasive therapeutic approach.

Endoscopic management of post-bariatric surgery complications

Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.

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.

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.

Bariatric surgery in patients with pulmonary hypertension

BACKGROUND Data regarding the outcomes of bariatric surgery in patients with pulmonary hypertension (PH) is limited. The aim of this study was to review our experience on bariatric surgery in patients with PH. SETTING An academic medical center. METHODS Patients with PH who underwent either a primary or revisional bariatric surgery between 2005 and 2015 and had a preoperative right ventricle systolic pressure (RVSP) ≥35 mm Hg were included. RESULTS Sixty-one patients met the inclusion criteria. Fifty (82%) were female with the median age of 58 years (interquartile range [IQR] 49-63). The median body mass index was 49 kg/m2 (IQR 43-54). Procedures performed included the following: Roux-en-Y gastric bypass (n = 33, 54%), sleeve gastrectomy (n = 24, 39%), adjustable gastric banding (n = 3, 5%), and banded gastric plication (n = 1, 2%). Four patients (7%) underwent revisional bariatric procedures. Median operative time and length of stay was 130 minutes (IQR 110-186) and 3 days (IQR 2-5), respectively. The 30-day complication rate was 16% (n = 10) with pulmonary complications noted in 4 patients. There was no 30-day mortality. One-year follow-up was available in 93% patients (n = 57). At 1 year, median body mass index and excess weight loss were 36 kg/m2 (IQR 33-41) and 51% (IQR 33-68), respectively. There was significant improvement in the RVSP after bariatric surgery at a median follow-up of 22 months (IQR 10-41). The median RVSP decreased from 44 (IQR 38-53) to 40 mm Hg (IQR 28-54) (P = .03). CONCLUSION Bariatric surgery can be performed without prohibitive complication rates in patients with PH. In our experience, bariatric patients with PH achieved significant weight loss and improvement in RVSP.

A Nationwide Safety Analysis of Discharge on the First Postoperative Day After Bariatric Surgery in Selected Patients

BackgroundEnhanced recovery after surgery has led to early recovery and shorter hospital stay after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). This study aims to assess feasibility and outcomes of postoperative day (POD) 1 discharge after LRYGB and LSG from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset.MethodsPatients who underwent elective LRYGB and LSG and were discharged on POD 1 and 2 were extracted from the MBSAQIP dataset. A 1:1 propensity score matching was performed between cases with POD 1 vs POD 2 discharge, and the 30-day outcomes of the cohorts were compared.ResultsA total of 80,464 patients met the study criteria: 8862 LRYGB and 31,370 LSG cases, which were discharged on POD 1, and matched 1:1 with those discharged on POD 2. Within the LRYGB cohort, patients discharged on POD 2 had higher all-cause morbidity (7.5% vs 6.1%; p < 0.001) and 30-day re-intervention (2.0% vs 1.5%; p = 0.004) in comparison with patients discharged on POD 1. There were no statistical differences with respect to serious morbidity (0.5% vs 0.4%; p = 0.15), 30-day readmission (4.9% vs 4.5%; p = 0.2), and 30-day reoperation (1.3% vs 1.2%; p = 0.7). Within the LSG cohort, patients discharged on POD 2 had higher all-cause morbidity (4.2% vs 3.4%; p < 0.001), serious morbidity (0.4% vs 0.3%; p < 0.001), 30-day re-intervention (1.0% vs 0.6%; p < 0.001), and 30-day readmission (2.9% vs 2.5%; p = 0.002) in comparison with patients discharged on POD 1.ConclusionsEarly discharge on POD 1 may be safe in a selective group of bariatric patients without significant comorbidities.

Comparison of laparoscopic jejunostomy tube to percutaneous endoscopic gastrostomy tube with jejunal extension: long-term durability and nutritional outcomes

IntroductionEnteral access through the jejunum is indicated when patients cannot tolerate oral intake or gastric feeding. While multiple approaches for feeding jejunal access exist, few studies have compared the efficacy of these techniques. The purpose of this study was to investigate the long-term durability, re-intervention rates, and nutritional outcomes following percutaneous endoscopic gastrostomy tubes with jejunal extension tubes (PEG-JET) versus laparoscopic jejunostomy tubes (j-tubes).MethodsRetrospective chart review was performed on all patients who underwent PEG-JET or laparoscopic jejunostomy tube placement from January 2005 through December 2015 at our institution. Thirty-day and long-term outcomes were compared between the two groups.ResultsA total of 105 patients underwent PEG-JET and 307 patients underwent laparoscopic j-tube placement during the defined study period. In terms of 30-day outcomes, patients who underwent PEG-JET placement were significantly more likely to experience a tube dislodgement event (p = 0.005) and undergo a re-intervention (p < 0.001). Patients who had a laparoscopic j-tube placed were significantly more likely to meet their enteral feeding goals (p = 0.002) and less likely to require nutritional supplementation with total parenteral nutrition (TPN) (p < 0.001). With regard to long-term outcomes, patients who underwent PEG-JET placement were significantly more likely to experience tube occlusion (p < 0.001) and require an endoscopic or surgical tube re-intervention (p < 0.001). Patients who underwent laparoscopic j-tube placement were significantly more likely to experience a tube site leak (p = 0.015) but were less likely to require nutritional supplementation with TPN (p = 0.001).ConclusionLaparoscopic jejunostomy tubes provide more durable long-term enteral access compared to PEG-JET. Consideration should be given to laparoscopic jejunostomy tube placement in eligible patients who cannot tolerate oral intake or gastric enteral feeding.

Adjustments To Warfarin Dosing Following Gastric Bypass and Sleeve Gastrectomy

Abstract 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 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.

Response to comment on: Upper gastrointestinal endoscopy is safe and feasible in the early postoperative period after Roux-en-Y gastric bypass

To the Editors: We thank Csendes for responding to our recently published article, “Upper gastrointestinal endoscopy is safe and feasible in the early postoperative period after Roux en-Y gastric bypass.” We appreciate the interest in our work, and we welcomed these comments. Our goal in examining this particular segment of patients was to evaluate the safety and feasibility of early, and not immediate, postoperative endoscopy after anastomosis formation. Our practice is to routinely perform intraoperative endoscopy on all patients, to assess not only for anastomotic integrity by means of submersion in saline and leak test, but also for other endoscopically detected findings, including hemorrhage, bezoar, and unusual pouch or anastomosis conformation. Data show that after initial anastomosis creation, there is a period of decrement in tissue strength as part of the normal healing process around days 1–3, and final strength is achieved by 4 weeks. Anecdotally, this has prompted many surgeons and endoscopists to refrain from endoscopic examination in the early postoperative period to avoid disruption from insufflation or intervention. We chose to define this time frame as 30 days and to apply data to challenge or support this notion. There is existing literature examining postoperative endoscopy after anastomosis formation at various time intervals, for both routine examination and for patient complaints that would prompt endoscopic evaluation. There is paucity, however, of studies that examine early endoscopy after the operative procedure for investigation of symptoms and/or complications specifically. This may in part be due to variability in the definition of “early endoscopy.” The previously published data by Csendes et al do indeed address this issue, though with a different study construct. In our study, we aimed to characterize the safety and feasibility of early endoscopy (#30 days), as well as document the findings in symptomatic patients at our comprehensive bariatric and metabolic surgery program. We commend the work of Csendes et al and their center’s experience on their previously published studies. These data contribute to an important segment of the literature to guide gastrointestinal surgeons and endoscopists. There are inherent shortcomings to the construct of our retrospective study, but the findings are helpful to guide physicians considering endoscopic evaluation of their patients. In our study, the majority of patients undergoing operative treatment were not included, as they had no symptoms requiring endoscopic examination. At our center and as a standard practice pattern in most United States health care systems, routine upper endoscopy after bariatric operation is not performed. Routine upper endoscopy would likely have yielded more pathology, but the clinical significance of this would be minimal, since it ultimately did not affect patient management. This may not represent the true incidence of pathology, but rather the incidence of pathology that prompted patient complaints or symptoms and, therefore, requires further endoscopic or medical management. We believe that our data and that of Csendes et al present complementary and not conflicting findings and that, as such, they contribute to the management of patients after bariatric operation. We also believe that the spectrum of practice, and publication, vary worldwide, and that by sharing through means of peer-reviewed data and examination of all literature, we can continue to advance the field of gastrointestinal surgery and endoscopy to best treat our patients. We thank Csendes for the comments and interest in our work.