Lars Nelson

Outcomes of Roux-en-Y gastric bypass in the super obese: comparison of body mass index 50–60 kg/m2 and≥60 kg/m2 with the morbidly obese☆

BACKGROUND Reports on the outcomes of Roux-en-Y gastric bypass (RYGB) in super-obese patients are limited, especially on patients with body mass index (BMI)≥60 kg/m(2). OBJECTIVES The aim of the present study was to evaluate and compare the tolerability and efficacy of RYGB in the super-obese by comparing patients with a BMI of 50-60 kg/m(2) and a BMI of≥60 kg/m(2) with patients with a BMI of 40-50 kg/m(2). SETTING Academic practice. METHODS Between January 2004 and November 2013, a total of 2717 patients underwent RYGB at our institution. Of these, 661 (24.3%) had a preoperative BMI of 50-60 kg/m(2) and 230 (8.5%) had a BMI≥60 kg/m(2). A retrospective review of outcomes and complications was performed, comparing these patients with 1555 patients with a BMI between 40-50 kg/m(2). RESULTS Fifty-two (3.3%) patients in the BMI 40-50 kg/m(2) group, 15 (2.3%) patients in the BMI 50-60 kg/m(2) group, and 3 (1.3%) patients in the BMI≥60 kg/m(2) had<30 days of follow-up. Readmission rates were 10.7%, 9.2%, and 11.7%, and reoperation rates were 7.3%, 5.0%, and 6.1%, in the BMI 40-50, 50-60, and≥60 kg/m(2) groups, respectively. No significant difference was found in readmission rate among the 3 groups, and reoperation rate was significantly lower in the BMI 50-60 kg/m(2) group. Mean percentage of excess BMI loss was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m(2) group; 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m(2) group; and 38.5%, 57.4%, 62.2%, 62.8%, and 59.1% in the≥60 kg/m(2) group at 6, 12, 18, 24, and 36 months, respectively. The differences in excess BMI loss were statistically significant among all 3 groups at all follow-up time points. All groups experienced a significant decrease in their mean number of co-morbidities after the procedure. CONCLUSION Readmission and reoperation rates were similar in the BMI 40-50, 50-60, and≥60 kg/m(2) groups. Super-obese and super-super-obese patients are not at greater risk for surgical complications compared with those with lower BMIs.

Duodenal stump leak following a duodenal switch: A case report

Highlights • We report a rare case of a duodenal stump blowout in a patient who underwent duodenal switch procedure.• We describe the possible presentation of the patient with a duodenal stump leak.• Management of anastomotic leaks should be done in the following order: stabilize the patient, drain the abscess, close the defect, and restore intestinal continuity.

SAFETY AND EFFECTIVENESS OF SINGLE ANASTOMOSIS DUODENAL SWITCH PROCEDURE: PRELIMINARY RESULT FROM A SINGLE INSTITUTION

ABSTRACT Background: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was introduced into bariatric surgery by Sanchez-Pernaute et al. as an advancement of the biliopancreatic diversion with duodenal switch. Aim: To evaluate the SADI-S procedure with regard to weight loss, comorbidity resolution, and complication rate in the super obese population. Methods: A retrospective chart review was performed on initial 72 patients who underwent laparoscopic or robot-assisted laparoscopic SADI-S between December 17th, 2013 and July 29th, 2015. Results: A total of 48 female and 21 male patients were included with a mean age of 42.4±10.0 years (range, 22-67). The mean body mass index (BMI) at the time of procedure was 58.4±8.3 kg/m2 (range, 42.3-91.8). Mean length of hospital stay was 4.3±2.6 days (range, 3-24). Thirty-day readmission rate was 4.3% (n=3), due to tachycardia (n=1), deep venous thrombosis (n=1), and viral gastroenteritis (n=1). Thirty-day reoperation rate was 5.8% (n=4) for perforation of the small bowel (n=1), leakage (n=1), duodenal stump leakage (n=1), and diagnostic laparoscopy (n=1). Percentage of excess weight loss (%EWL) was 28.5±8.8 % (range, 13.3-45.0) at three months (n=28), 41.7±11.1 % (range, 19.6-69.6) at six months (n=50), and 61.6±12.0 % (range, 40.1-91.2) at 12 months (n=23) after the procedure. A total of 18 patients (26.1%) presented with type II diabetes mellitus at the time of surgery. Of these patients, 9 (50.0%) had their diabetes resolved, and six (33.3%) had it improved by 6-12 months after SADI-S. Conclusions: SADI-S is a feasible operation with a promising weight loss and diabetes resolution in the super-obese population.

Laparoscopic Roux-en-Y gastric bypass in a patient with situs inversus

/10.10 16 A ence: Baria paros FL, U amma Situs inversus is a rare genetic condition resulting from autosomal recessive genetic mutation or, less commonly, an X-linked genetic mutation [1]. It occurs at a frequency of 1:5,000 to 1:10,000 live births and is defined by a left-right transposition of all viscera as a mirror image. In its most common form, situs inversus totalis, it presents with complete transposition of all viscera, with the liver being palpable in the left upper quadrant. Patients also have rightsided stomach, left-sided inferior vena cava, right atria on the left side, and left atria on the right side. Partial situs inversus may involve the stomach, small bowel, or large bowel, but the liver is located in its usual position in the right upper quadrant. Approximately 70% of patients with situs inversus have other congenital abnormalities of the gastrointestinal tract [2]. Our patient presented without any other congenital abnormality and had situs inversus totalis with complete transposition of all viscera. Roux-en-Y gastric bypass (RYGB) is a means of durable sustainable weight loss and superior to diet, exercise, and medical management alone. There are limited published data on situs inversus and even less on patients undergoing RYGB with this abnormal condition. We report a case of successfully performed RYGB in a patient with atypical anatomy consistent with situs inversus totalis.

Techniques of Single-Stage Laparoscopic Conversion of Roux-en-Y Gastric Bypass to Single Anastomosis Bilio-pancreatic Diversion with Duodenal Switch

BackgroundConversion of Roux-en-Y gastric bypass (RYGB) to single anastomosis duodenal switch can be a complicated and time-consuming operation for surgeons.PurposeThe purpose of this article is to present our technique of single-step laparoscopic conversion of RYGB to single anastomosis duodenal switch bilio-pancreatic diversion and vertical sleeve gastrectomy, creating a 250-cm common channel.Material and MethodsA laparoscopic technique was utilized in the conversion.ResultsAfter the gastrojejunostomy is completely separated from the gastric remnant, a sleeve gastrectomy was created followed by duodeno-ileal anastomosis.ConclusionConversion of RYGB to single anastomosis duodenal switch can be a complicated operation, requiring a two-stage approach in most cases. With the adoption of the described technique, it can be easier to be achieved in a single-stage.

Methylene Blue or Upper GI, Which is More Effective for Detecting Leaks in Gastric Bypass Patients?

Background: Postoperative leaks from the staple lines are a serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB) that results in morbidity and could even lead to mortality. Bariatric surgeons have several tools to assess this adversity. There have been debates as to which method is more superior and furthermore whether these methods should be routinely or selectively used. The aim of our study is to evaluate and compare whether methylene blue or upper gastrointestinal (UGI) study is more effective in detecting an anastomotic leak after RYGB. Materials and Methods: Between May 2013 and March 2014, 119 patients underwent laparoscopic RYGB. Linear staplers were used to create the gastrojejunostomy and the jejunojejunostomy. All patients underwent routine UGI studies and methylene blue challenges on postoperative day 1. A retrospective review of a prospectively collected database was performed for all patients. Results: Of the 105 patients in this study there were 83 females (79.0%) and 22 males (21.0%). Mean age was 45.2±10.7 years (range, 21 to 66 y) and mean preoperative body mass index was 47.8±7.9 kg/m2 (range, 35.7 to 76.4 kg/m2) at the time of procedure. Mean length of hospital stay was 3.2±6.0 days (range, 1 to 53 d). Four (3.8%) patients were found to have leaks postoperatively, but no leakage was detected in any of the initial routine UGI studies or methylene blue challenges. Both patient were diagnosed with clinical signs and underwent oversewing of the leak sites. Conclusions: UGI studies and methylene blue challenges had no significant difference in detecting a postoperative leak. Furthermore, these tests may have limited utility and may warrant adjuncts to aid in leak detection.