Lester Carrodeguas

Management of Ulcerative Colitis in the Morbidly Obese Patient: Is Bariatric Surgery Indicated?

Ulcerative colitis and obesity share a systemic chronic inflammatory response manifested by increased inflammatory markers. There are data suggesting a benefit in both diseases after inflammatory markers are decreased. We present a 39-year-old morbidly obese male with a history of ulcerative colitis who manifested significant symptomatic improvement after an 86.8% excess weight loss following gastric bypass surgery. We believe that this result may have been due to a reduction of inflammatory markers secondary to considerable weight loss. Although to our knowledge there are no publications showing a direct relationship between symptomatic improvement of ulcerative colitis and weight loss in the obese patient, we believe that weight loss surgery could become a promising tool in the treatment of ulcerative colitis when associated with morbid obesity.

Development of Acute Gouty Attack in the Morbidly Obese Population after Bariatric Surgery

Background: Gout is associated with increased body weight. We evaluated the prevalence of gout and acute gouty attacks in the morbidly obese population who underwent bariatric surgery. Methods: The medical records and operative reports of 1,240 patients who underwent bariatric surgery were reviewed retrospectively for weight parameters, BMI, weight loss, medical history of gout, and onset of acute gouty attacks. Results: Of the 1,240 patients, 5 (0.4%) had been previously diagnosed with gout. 2 of these 5 had acute attacks during the postoperative period, and responded succesfully to intravenous colchicine. Conclusion: Although rare, gout must be considered a co-morbid illness in obese and morbidly obese patients. Surgeons should be familiar with the signs and symptoms of attacks in the postoperative period, and be knowledgeable in the management.

Stricture rates after circular stapled vs. linear stapled gastro-jejunostomy for laparoscopic gastric bypass

ZusammenfassungGRUNDLAGEN: Strikturraten der Gastrojejunostomie (GJA) bei laparoskopischem Magenbypass (LGBP) werden 1,6%–40% für zirkulären und 3%–14,6% für linearen Stapler angegeben. Diese Studie hat beide Anastomosentechniken in Hinblick auf die Strikturrate verglichen. METHODIK: Prospektive Studie, es wurde Magenbypass mit antekolischer, antegastrischer Y-Roux-Anastomose mit zirkulärem 25 mm Stapler vs. Linearstapler (+2 fortlaufende Nähte) verglichen. Strikturdefinition: symptomatische Wegsamkeitsstörung, die endoskopische Ballondilatation zur Wiederherstellung der Durchgängigkeit für ein 9,8 mm Endoskop benötigte. Werte wurden als Median und Range angegeben. ERGEBNISSE: Keine Mortalität. 39 Patienten in jeder Gruppe, mit vergleichbarem Alter und Geschlechtsverteilung, Anästhesiescore, BMI (46,2 vs. 51) und Begleiterkrankungen. Blutverlust, Spitalsaufenthaltsdauer, Komplikationen und Re-Operationen waren vergleichbar. OP-Zeit war länger und Konversion häufiger bei zirkulärer Staplertechnik (p < 0,001). Strikturraten und endoskopische Ballondilatation waren vergleichbar (p = 0,146 bzw. 0,146). SCHLUSSFOLGERUNGEN: Es fand sich kein signifikanter Unterschied bezüglich Strukturrate nach zirkuläre vs. linear gestapelter Gastrojejunostomie bei laparoskopischem Magenbypass. Größere Studien mit entsprechender Strikturklassifikation sind zu empfehlen.SummaryBACKGROUND: The literature shows that stricture rates at gastrojejunal anastomosis (GJA) following laparoscopic gastric bypass (LGBP) vary from 1.6% to 40% for circular stapled (CSA) and 3% to 14.6% for linear stapled (LSA) GJA. The aim of this study was to evaluate whether circular stapled versus linear stapled GJA impacts stricture rates. METHODS: This was a prospective, concurrent cohort study. Patients underwent ante-colic, ante-gastric Roux-en-Y LGBP with either circular stapled GJA (25-mm circular stapler) or with linear stapled GJA (2 layers of running sutures). GJA stricture was defined by obstructive symptoms with a GJA requiring endoscopic balloon dilatation to allow passage of a 9.8 mm endoscope. Values were median (range). RESULTS: There were no deaths. There were 39 patients in the CSA and 39 patients in the LSA arms. Patients were well-matched for age 41 (23–55) vs. 44 (29–62) years, gender (35: 4 vs. 31: 8), American Society of Anesthesiology score (14: 20: 5 vs. 0: 38: 1), body mass index 46.2 (35–66.7) vs. 51.0 (37–73) and co-morbidities 4 (2–10) vs. 4 (1–7). There were no significant differences in estimated blood loss 50 (50–3000) vs. 50 (50–75) ml, length of stay 4 (3–48) vs. 4 (3–8) days, complications (7 vs. 3) and re-operations (2 vs. 2). Operating time 196 (140–370) vs. 90 (60–120) (p ≪ 0.001) min, conversions (7 vs. 0 p = 0.002), and differed. Stricture (7 vs. 2 p = 0.146) and endoscopic balloon dilation (12 vs. 4 p = 0.083) rates at a follow-up of 12 (8–18) months did not differ significantly. Time to presentation after surgery for the strictures was 36.5 (33–42) vs. 26.5 (24–29) days in the CSA and in the LSA arms, respectively. The percentage of excess body weight loss at 1 year was similar (80% vs. 78%). CONCLUSIONS: This underpowered study did not detect a significant difference in stricture rates at the GJA after CSA or LSA. Strictures were safely and successfully treated by endoscopic balloon dilation. Larger studies with a widely accepted classification of GJA stricture would be appropriate.

Topical anesthesia-induced methemoglobinemia in bariatric surgery patients.

Methemoglobinemia leads to rapid oxygen desaturation, requiring prompt recognition and treatment. We present two severely obese patients who developed methemoglobinemia following the use of topical or local anesthetic. This complication was detected by analysis of arterial blood gases, and was successfully treated with methylene blue IV and 100% O2 supplementation.

Myasthenia gravis improvement after laparoscopic Roux-en-Y gastric bypass.

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m2, and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.