Jorge E. Urbandt

Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients

BACKGROUND Although vertical banded gastroplasty (VBG) was endorsed by the 1991 National Institutes of Health Consensus Conference for the treatment of morbid obesity, it has largely been abandoned owing to the poor long-term weight loss and band-related complications. The objective of the present study was to review the outcomes of patients who had undergone laparoscopic conversion of VBG to Roux-en-Y gastric bypass (RYGB) for weight loss or dysphagia and gastroesophageal reflux. METHODS A retrospective review of prospectively collected data from all patients who had undergone revision of VBG to RYGB was performed. The data on the symptoms, weight loss, co-morbidities, and complications were collected. RESULTS From July 1999 to April 2010, 2397 bariatric procedures were performed. Of these, 105 (4.4%) were laparoscopic revisions of previous VBG to RYGB. Of the 105 patients, 103 had undergone open VBG and 2 laparoscopic VBG. Of the 105 patients, 97 were women and 8 were men. The average patient age was 49 years (range 23-71). The median preoperative body mass index was 42 kg/m(2) (range 20-72). Short- and long-term complications occurred in 40 patients (38%). No patients died. The median length of stay was 2 days. At an average follow-up of 31 months (range 1-96), the median percentage of excess weight loss was 47% (range -24% to 138%). The median decrease in body mass index was 8 kg/m(2) (range -6 to 30). Dysphagia had improved or resolved in 100%. Gastroesophageal reflux disease had improved or resolved in 95%. Diabetes had improved or went into remission in 90%. Hypertension had improved or resolved in 62%. Obstructive sleep apnea had improved or resolved in 96%. CONCLUSION The results of our study have shown that laparoscopic revision of VBG to RYGB is a feasible procedure that can provide acceptable weight loss and reversal of weight-related co-morbidities. Complications were common after revisional bariatric surgery.

Obesity surgery and malignancy: our experience after 1500 cases

BACKGROUND Obesity is a risk factor for cancer and is associated with increased mortality from a number of malignancies. We describe our experience with bariatric surgery patients with a history of malignancy and review the safety and outcomes of bariatric surgery in patients with a history of cancer. METHODS We performed a retrospective review of prospectively collected data from all patients diagnosed with a malignancy before, during, or after bariatric surgery. Data on weight loss, co-morbidities, and recurrence were collected. RESULTS From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 36 (2.3%) had a history of malignancy before they underwent bariatric evaluation and surgery, 4 (0.26%) were diagnosed with a malignancy during their preoperative evaluation, 2 of whom subsequently underwent bariatric surgery, and 2 had intraoperative findings suspicious for malignancy; bariatric surgery was completed in both cases. The evaluation revealed renal cell carcinoma and low-grade lymphoma, respectively. No procedures were aborted because of a suspicion of malignancy. Postoperatively, 16 patients (0.9%) were diagnosed with cancer, 3 of whom had a history of malignancy: 1 with metastatic renal cell, 1 with recurrent melanoma, and 1, who had had prostate cancer, with bladder cancer. CONCLUSION A history of malignancy does not appear to be a contraindication for bariatric surgery as long as the life expectancy is reasonable. Screening for bariatric surgery might reveal the malignancy. Bariatric surgery does not seem to have a negative effect on the treatment of malignancies that are discovered in the postoperative period.

Effect of immunosuppression on patients undergoing bariatric surgery

BACKGROUND Immunocompromised patients are at high risk of medical complications. Immunosuppression might be a relative contraindication to bariatric surgery. We describe our experience with immunosuppressed patients undergoing bariatric surgery and review the safety, efficacy, results, and outcomes. METHODS We performed a retrospective review of prospectively collected data. All patients taking long-term immunosuppressive medications or with a diagnosis of an immunosuppressive condition were included in this study. Data on weight loss, co-morbidities, complications, and postoperative immunosuppression were collected. RESULTS From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 61 (3.9%) were taking immunosuppressive medications or had an immunosuppressive condition. Of these 61 patients, 49 were taking immunosuppressive medications for asthma, autoimmune disorders, endocrine deficiency, or chronic inflammatory disorders. The medications included oral, inhaled, and topical glucocorticoids for 39 patients and other immunosuppressive or disease-modifying antirheumatic drugs for 24 patients. The bariatric procedures included laparoscopic Roux-en-Y gastric bypass in 55, laparoscopic revisional procedures in 5, and laparoscopic sleeve gastrectomy in 1. No patient died perioperatively. A total of 26 complications occurred in 20 patients. The average percentage of excess weight loss was 72% (range 20-109%) at 1 year postoperatively. At a median postoperative follow-up of 18 months (range 2-68.6), 25 (51%) of 49 patients no longer required immunosuppressive medications owing to improvement of their underlying disease. Obesity-related health problems (diabetes mellitus, hypertension, obstructive sleep apnea, gastroesophageal reflux disease, asthma) had resolved or improved in 80-100% of patients. CONCLUSION The results of our study have shown that immunocompromised patients can safely undergo bariatric surgery with good weight loss results and improvement in co-morbidities. A large percentage of patients were able to discontinue immunosuppressive medications postoperatively.

Malrotation—an unexpected finding at laparoscopic Roux-en-Y gastric bypass: a video case report

A 38-year-old woman with a long history of severe besity and a body mass index of 48 kg/m elected to undergo LRYGB. She had a medical history of pulmonary embolism and laparoscopic cholecystectomy for symptomatic cholelithiasis. She did not undergo any preoperative abdominal radiological studies, and no mention had been made of abnormalities at her laparoscopic cholecystectomy. After placement of the umbilical camera trocar, the initial inspection of the abdominal cavity revealed what appeared to be a mobile cecum and easily visualized appendix (see video). On retrospect, this should have alerted us to the possibility of midgut malrotation. Additional trocars were placed (Fig. 1), and the gastric pouch was created. The omentum was then grasped in an attempt to elevate the omentum and transverse colon cephalad. At first, it was thought that adhesions were tethering the transverse colon, but we then realized that the entire

Laparoscopic revision of Roux-en-Y gastric bypass for dysphagia and bile reflux

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is 1 of the most common procedures performed for severe obesity. Complications are not uncommon, and the evaluation for symptoms of abdominal pain and dysphagia can be difficult. Extensive evaluation can require upper gastrointestinal (GI) radiologic series, endoscopy, and abdominal computed tomography to help in the diagnosis. Some of these patients could require revisional procedures to alleviate their symptoms. We present a video case report of a patient with chronic abdominal pain, dysphagia, and vomiting due to a hiatal hernia, bile reflux, and a poorly emptying pouch. The video demonstrates the laparoscopic revision of the gastric pouch and gastrojejunal anastomosis, revision of the Roux limb, hiatal hernia repair, and gastrostomy tube placement.