Julietta Chang

Predictive factors of biliary complications after bariatric surgery

BACKGROUND Obesity and rapid weight loss are risk factors for gallstone development. Bariatric surgery and significant postoperative weight loss are associated with postoperative biliary complications. OBJECTIVE We aim to identify predictive factors of biliary complications after bariatric surgery. SETTING University hospital. METHODS After Institutional Review Board approval, charts at a single institution were reviewed to identify patients with biliary complications after bariatric surgery from 2005 to 2012. Data collected included baseline patients demographic characteristics, perioperative parameters, and postoperative biliary complications. Parameters were analyzed using paired and unpaired Student t test for continuous variables and χ2 test for categorical variables. Univariate and multivariate analyses were used to assess risk factors for complications after bariatric surgery. All tests were 2 tailed; results with P<.05 were considered statistically significant. RESULTS One hundred thirty-eight (3.6%) of 3765 patients who underwent bariatric surgery developed postoperative biliary complications. Mean time from surgery to biliary complication was 1.8±1.4 years. Complications included acute cholecystitis (18.1%), chronic cholecystitis (70.2%), acute pancreatitis (9.4%), choledocholithiasis (5.7%), and jaundice (2.8%). Interventions were laparoscopic (n = 134, 97.0%) and open (n = 1, .7%) cholecystectomy. Forty patients (28.9%) had known cholelithiasis before surgery. There were no mortalities. Univariate analysis identified female gender, age>50, cholelithiasis at time of bariatric procedure, and Roux-en-Y gastric bypass independent of excess weight loss as predictive factors of biliary complications. Multivariate analysis confirmed advanced age as an independent predictive factor. CONCLUSION The results of our study suggest that patients of advanced age are at higher risk of biliary complications. However, the indications for prophylactic cholecystectomy at time of bariatric surgery remain unclear.

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.

ASMBS Updated Position Statement on Bariatric Surgery in Class I Obesity (BMI 30-35 kg/m2)

Preamble The American Society for Metabolic and Bariatric Surgery (ASMBS) issued a position statement on the role of bariatric surgery in class I obesity in 2012 [1]. That statement was developed in response to inquiries made to the ASMBS by society members, physicians, patients, hospitals, health insurance payers, policy makers, and the media regarding the safety and efficacy of bariatric surgery for patients with body mass index (BMI) 30-35 kg/m 2 . In the evolving field of bariatric and metabolic surgery, The Clinical Issues Committee of ASMBS recognized the necessity to update the position statement since additional high quality data has emerged in the past 5 years to support bariatric surgery in class I obesity. In this updated statement, the ASMBS recommendations are presented that are derived from available knowledge, peer-reviewed scientific literature, and expert opinion. The statement may be revised in the future should additional evidence become available. The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care.

Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: further support for bariatric surgery in patients without metabolic disease?

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) increases the risk of liver cirrhosis and hepatocellular carcinoma and is also strongly correlated with extrahepatic diseases, including cardiovascular disease and type 2 diabetes. This risk of NAFLD among obese individuals who are otherwise metabolically healthy is not well characterized. OBJECTIVES To determine the prevalence and characteristics of NAFLD in individuals with metabolically healthy obesity. SETTING A tertiary, academic, referral hospital. METHODS All patients who underwent bariatric surgery with intraoperative liver biopsy from 2008 to 2015 were identified. Patients with preoperative hypertension, dyslipidemia, or prediabetes/diabetes were excluded to identify a cohort of metabolically healthy obesity patients. Liver biopsy reports were reviewed to determine the prevalence of NAFLD. RESULTS A total of 270 patients (7.0% of the total bariatric surgery patients) met the strict inclusion criteria for metabolically healthy obesity. The average age was 38 ± 10 years and the average body mass index was 47 ± 7 kg/m2. Abnormal alanine aminotransferase (>45 U/L) and asparate aminotransferase levels (>40 U/L) were observed in 28 (10.4%) and 18 (6.7%) patients, respectively. A total of 96 (35.5%) patients had NAFLD with NALFD Activity Scores 0 to 2 (n = 61), 3 to 4 (n = 25), and 5 to 8 (n = 10). A total of 62 (23%) patients had lobular inflammation, 23 (8.5%) had hepatocyte ballooning, 22 (8.2%) had steatohepatitis, and 12 (4.4%) had liver fibrosis. CONCLUSION Even with the use of strict criteria to eliminate all patients with any metabolic problems, a significant proportion of metabolically healthy patients had unsuspected NAFLD. The need and clinical utility of routine screening of obese patients for fatty liver disease and the role of bariatric surgery in the management of NAFLD warrants further investigation.

Gastrointestinal devices for the treatment of type 2 diabetes

BACKGROUND Obesity and type 2 diabetes (T2D) continue to be growing epidemics worldwide. Although bariatric surgery remains the most effective and durable treatment for both of these chronic diseases, there is a need for therapies with risk and benefit profiles between medication and standard surgical procedures. Currently there are several endoscopic and minimally invasive therapies available worldwide to treat T2D. OBJECTIVE To review the current evidence regarding the safety and efficacy of medical devices to treat T2D. SETTING Academic practice, international METHODS The published literature was searched for articles evaluating the safety and efficacy of endoluminal and surgical devices used for the treatment of obesity and T2D. RESULTS The current devices in use include intragastric balloons, a duodenal-jejunal liner, gastric content aspiration, and devices that provide neuromodulation to the stomach or vagal nerves. On early phases of first-in-human studies is the duodenal mucosal resurfacing. The current evidence supporting the safety and efficacy of temporary use (6 months) for the intragastric balloon for lower body mass index (BMI) patients is strong and there is growing evidence regarding the effects of the other devices to treat T2D. CONCLUSIONS There is a need for novel therapies to bridge the risk and benefit gap between medical and surgical treatment of T2D. The original indication for many of the current devices was treatment of obesity. Several devices that are currently available are promising but require more study in T2D patient populations.

475 Natural History of Primary Fundoplication in the Obese: A Multicenter Study

and after transplantation. Methods: This was a retrospective cohort study of lung transplant patients undergoing ARS before or after transplantation at a tertiary care center since 2007, with at least one year follow-up. Early allograft injury was defined clinically and histologically as acute rejection or lymphocytic bronchiolitis, occurring within the first year after transplantation. In accordance with prior studies, the cutoff between early and late post-transplant ARS was 6 months. Time-to-event analysis using the Cox proportional hazards model was applied to assess the relationship between timing of surgery and early allograft injury. Subjects not meeting this outcome were censored at one year in the time-to-event analysis. Fishers exact test for binary variables and students t-test for continuous variables were performed to assess for differences between surgical timing groups. Results: 48 subjects (60% men, mean age: 55, average follow-up: 3.5 years) met inclusion criteria for the study. Patient demographics, pre-transplant cardiopulmonary function, BMI, CMV status, and PPI exposure were similar between groups. Kaplan-Meier analysis (Figure 1) demonstrated significantly increased early allograft injury in late post-transplant ARS patients compared with both pre-transplant (log-rank p=0.007) and early post-transplant (log-rank p=0.05) patients, as well as a significant trend across groups (log-rank p=0.005). No significant difference between pre-transplant and early post-transplant groups was noted (Table 1). Complications were rare and identified in 1 pre-transplant fundoplication patient with recurrent symptoms requiring re-operation, and in 3 late post-transplant ARS patients: 2 with recurrent symptoms and regurgitation requiring re-operation, and 1 with aspiration pneumonia resulting in death. No early post-transplant ARS patients experienced complications. Conclusion: Late post-lung transplant ARS resulted in increased risk of early allograft injury compared to pre-transplant and early post-transplant ARS. Both pre-transplant and early post-transplant ARS appear equally safe and effective in improving lung transplant outcomes. These findings support consideration of anti-reflux measures before and soon after transplantation to minimize the impact of reflux on allograft injury and longer term outcomes.

Robotic Partial and Total Gastrectomy

Robotic gastrectomy was first described in 2003 for gastric cancer. Since then, robotic-assisted resection has demonstrated advantages for early gastric cancer with respect to decreased blood loss and potentially greater number of retrieved lymph nodes. Technical benefits of robotics include enhanced visualization and greater range of instrument movement; due to this, the robotic technology has been used for gastric resection for benign disease such as peptic ulcer disease as well. This chapter will aim to discuss the indications for the application of robotic-assisted gastrectomy in both malignant and benign disease; the technical aspects in the use of robotics in these surgeries; the potential advantages of the use of the robot in these cases; and future directions.

Minimally Invasive Gastrostomy

The establishment of enteral access for feeding is one of the most common pediatric surgical procedures. Many techniques have been described in the armamentarium of the pediatric surgeon, and choice of technique is dictated by patient selection and surgeon preference. The three most common are open Stamm gastrostomy, laparoscopic gastrostomy, and percutaneous endoscopic gastrostomy (PEG). All three have been demonstrated to be feasible in the pediatric population. This chapter aims to outline the history of gastrostomy in the use of feeding access and describe techniques in minimally invasive gastrostomy placement, namely, laparoscopic gastrostomy and PEG.

Medical Devices in the Treatment of Obesity

Obesity continues to be a growing epidemic worldwide. Although bariatric surgery remains the most effective and durable treatment of obesity and its comorbidities, there is a need for less invasive yet efficacious weight loss therapies. Currently the Food and Drug Administration has approved two endoscopically placed intragastric balloon devices and a surgically placed vagal blockade device. Another device that holds promise, particularly for the treatment of type 2 diabetes, is the endoscopically placed duodenojejunal bypass sleeve. This article reviews the indications and current data regarding results for these devices.