Mena Boules

The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery.

PURPOSE To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery. METHODS We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes. RESULTS A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m(2). A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m(2), and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes. CONCLUSION The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.

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.

Median Arcuate Ligament Syndrome Is Not a Vascular Disease

BACKGROUND Median arcuate ligament syndrome (MALS) is a rare disorder characterized by postprandial abdominal pain, weight loss, and celiac stenosis. Diagnosis can be challenging, leading to a delay in treatment. We report on our continued experience using a laparoscopic approach for this uncommon diagnosis. METHODS This is an Institutional Review Board-approved, prospectively collected retrospective analysis of patients treated with laparoscopic MAL release at our institution. Data collected included patient demographics, preoperative symptoms, operative approach, and postoperative outcomes. Patients were then contacted to complete a postoperative survey designed to assess the improvement of symptoms and overall patient satisfaction. RESULTS A total of 39 patients (33 women and 6 men) underwent laparoscopic MAL release from March 2007 to July 2014. Mean age was 40.6 years (range, 17-77 years). Thirty of 39 patients had a postoperative celiac axis ultrasound. Twenty-three had a patent celiac axis on postoperative duplex. Of the remaining 7, 5 with residual celiac axis stenosis and 1 with occlusion, reported complete resolution of their symptoms. One remaining patient with occlusion remained symptomatic. Thirty-three of 39 (84.6%) reported symptom relief after surgery. Nine of 33 (27.3%) responders had cardiovascular risk factors versus 4 of 6 (67%) nonresponders. Five patients with atypical presentations underwent preoperative diagnostic celiac plexus block using local anesthetic, with 4 reporting symptom reliefs after block. These 4 patients also reported postoperative symptom relief. One patient of 39 received a postoperative celiac stent placement and remained symptomatic. There were 4 conversions to open surgery (10.3%) and no deaths. CONCLUSIONS Laparoscopic MAL release continues to be a safe and effective means of managing MALS. Our data suggest that the symptoms associated with MALS are not related to vascular compromise, and atherosclerotic risk factors may predict poorer outcomes. Symptomatic relief is seen in the vast majority of patients undergoing this procedure. However, patient selection remains critically important in obtaining optimal results.

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.

Revisional bariatric surgery can improve refractory metabolic disease

BACKGROUND It remains unclear if patients undergoing revisional surgery for inadequate weight loss/recidivism can achieve improvement of refractory metabolic syndrome (MetS). OBJECTIVE We aimed to evaluate metabolic outcomes after reoperative bariatric surgery for unsatisfactory weight loss in patients with refractory MetS. SETTING Academic Hospital. METHODS We retrospectively reviewed all revisional bariatric surgery cases performed for inadequate weight loss/recidivism at our center and analyzed all cases in which the patient had ongoing uncontrolled diabetes or MetS. RESULTS In total, 121 reoperative bariatric cases for inadequate weight loss/recidivism were identified. Of those, 31.4% (N = 38) had MetS and 33.9% (N = 41) were diabetic at the time of primary bariatric surgery. At revisional surgery, 15 (39.5%) patients still met criteria for MetS and 7 (17.1%) had hemoglobin A1c (HbA1c)≥6.0%. Of those with refractory MetS (N = 15) at revisional surgery, a mean percent excess weight loss (%EWL) of 59.4±21.2% at mean 40.1±29.9 months follow-up corresponded to a mean decrease in triglyceride of 65.2 mg/dL, mean increase in high-density lipoprotein cholesterol (HDL) of 12.1 mg/dL, and mean decrease in plasma glucose of 58.8 mg/dL. Mean percent total weight loss was 27.3%. One patient still met criteria for MetS. Of those with HbA1c≥6.0% at reoperative surgery (N = 7), a mean %EWL of 63.0±22.9% at mean 51.6±36.6 months follow-up corresponded to a mean decrease in HbA1c of 1.6%. Three patients still had HbA1c≥6.0%, but only 1 had HbA1c≥ 6.5%. CONCLUSION Although further research is needed, this report suggests that revisional bariatric surgery is capable of treating both inadequate weight loss and refractory metabolic disease.

Factors associated with length of stay in intensive care after bariatric surgery

BACKGROUND Although uncommon, admission to the intensive care unit (ICU) after bariatric surgery may be necessary. This study evaluates characteristics of bariatric surgery patients that are admitted to the ICU, and identifies possible risk factors for increased ICU length of stay (LOS). SETTING Academic hospital, United States. METHODS A retrospective review of all ICU admissions after bariatric surgery from 2006 to 2013 was performed. Demographic characteristics and perioperative data were extracted, and risk factors for the LOS and mortality in the ICU were analyzed. RESULTS In total, 124 out of 4398 (2.8%) patients were admitted to the ICU after bariatric surgery. The mean age of these patients was 52.7±11.8 years and included 79 female patients (64%). There were 19 nonemergent or planned admissions (15.3%) and 105 unplanned admissions (84.7%). Mean body mass index was 47.8±12.2 kg/m2, and mean American Society of Anesthesiology (ASA) score was 3.1±0.6. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 80 (65%), 18 (15%), and 6 (5%) patients, respectively. Revisional procedures were performed in 15 (12%) patients. Respiratory failure was the most common cause for admission, occurring in 35 (28.2%) patients. The most common surgical complications requiring ICU admission were bleeding (n = 27) and anastomotic leak (n = 21). Mean ICU LOS was 6.0±9.6 (1-65) days. Mortality occurred in 5 (4.0%) patients. Based on univariate analysis, risk factors associated with ICU LOS were conversion from laparoscopic to open approach, anastomotic leak, time from operation to ICU admission, and reoperation. Higher ASA score was a significant risk factor for mortality. CONCLUSION ICU admission after bariatric surgery is uncommon but is associated with a significantly increased mortality. Anastomotic leak, conversions, time from operation to ICU admission, and reoperation have the greatest impact in determining the LOS in the ICU after bariatric surgery.

Laparoscopic Three-Port Sleeve Gastrectomy: A Single Institution Case Series

BACKGROUND Further minimization of abdominal wall trauma during laparoscopic bariatric surgery is a topic of great interest. Reducing the number of trocars may provide superior cosmetic results with less pain and shorter length of stay (LOS). However, it remains unclear if this approach compromises safety or effectiveness of weight loss. The aim of this study is to report initial safety and feasibility results using a three-port minimally invasive sleeve gastrectomy technique. MATERIALS AND METHODS A retrospective review of patients who underwent laparoscopic three-port sleeve gastrectomy (3PSG) at our institution was conducted. Patient demographics, intraoperative parameters, and perioperative outcomes were extracted and analyzed. Postoperative data were obtained from routine follow-up history and physical examination. RESULTS From May 2013 to April 2014, 45 morbidly obese patients underwent 3PSG. The cohort had a male-to-female ratio of 20:25, mean age of 47.4 ± 11.6 years, and a mean preoperative body mass index (BMI) of 47.6 ± 9.7 kg/m(2). The mean number of comorbidities was 4 (range 0-8), and the mean American Society of Anesthesiologists score was 2.82 (range 1-4). Mean procedural duration and blood loss were 165 ± 31.9 minutes and 27.0 ± 31.8 mL, respectively. Eight patients (17%) required one additional trocar. Two cases (4.4%) had an intraoperative complication (staple line bleeding and splenic capsule laceration). Two (4.4%) postoperative complications were encountered (wound infection and axillary vein thrombosis). The mean LOS was 2.7 (range 2-7) days. At a mean follow-up of 5 (range 0.4-11.7) months, the cohort had a mean BMI of 40.0 ± 9.26 kg/m(2), which corresponded to a mean excess weight loss of 36.0% ± 18.1%. There were no trocar site hernias. All patients were highly satisfied with the final cosmetic result. CONCLUSION Laparoscopic 3PSG appears to be a safe and feasible technique for performing sleeve gastrectomy. While further long-term research is needed, it appears to have significant benefits, mainly patient satisfaction and potentially less pain.

Automated recall system for colonoscopy: a generalizable informatics solution for procedures requiring timely follow-up

Specifically, at most institutions, pathology systems do not integrate with the main electronic health record (EHR) or endoscopic electronic record system (EERS) in a way that allows for discrete data capture. Given that EHR is the primary tool used by physicians and, as such, becomes the legal record of choice, any registry or reporting tool that does not incorporate EHR in some way forces the physician to enter data redundantly, and adversely impacts work flow and efficiency. These barriers impede quality measurement and risk stratification and thereby limit adoption of nationwide quality improvement initiatives like GIQUIC. This pilot study presents a programming solution that is able to marry patient communication with capturing of discrete data within EHR, which can be bundled with quality metrics captured within EERS, and can be uploaded to registry and reporting tools in an automated fashion. Additionally, the programming solution populates a recall registry that can be used to generate reminder letters to patients, all without any significant disruption to physician work-flow or manual input. The solution is now being piloted in a second institution and uses a generalizable approach that can be adopted by most institutions or practices, irrespective of the type of EHR or EERS used.

Percutaneous Endoscopic Gastrostomy for Decompression of Nonmalignant Gastrointestinal Disease

INTRODUCTION The utility of percutaneous endoscopic gastrostomy (PEG) decompression for inoperable malignant bowel obstruction is well documented. However, there are limited data on decompressive PEG for prolonged ileus, gut dysmotility, and/or complicated nonmalignant bowel obstruction. The aim of this study was to assess the safety and short-term outcomes of decompressive PEG for nonmalignant indications. SUBJECTS AND METHODS After Institutional Review Board approval, we retrospectively reviewed and analyzed all PEG insertions completed at our institution between 2009 and 2014 for prolonged ileus, gut dysmotility, or nonmalignant obstruction. RESULTS We identified 72 patients (42 females, 30 males; mean age, 58.8 ± 15.2 years) who underwent decompressive PEG for nonmalignant indications. There were no procedural complications or mortalities. The mean pre- and postprocedural length of stays were 14.4 ± 10.7 and 7.6 ± 11.1 days, respectively (P = .0003). The 30-day re-admission rate was 12.5% (9 patients; the majority for unrelated issues). Fifty-two (72%) of the 72 patients were discharged with a PEG for decompression for a median of 69.5 (range, 17-316) days; the remaining 20 (28%) patients were lost to follow-up and were assumed to continue follow-up with their primary referring center. Of the 72 patients, 63 (87.5%) were discharged on total parenteral nutrition (TPN); 36 (50%) of those continued to receive TPN for a median of 51 (range, 4-316) days after discharge, and resolution of their mechanical obstruction was ultimately achieved, so that they subsequently resumed enteral nutrition. Twenty-four (33%) patients were lost to follow-up; because they were referred to our tertiary referral center, we assumed they continued follow-up at their referring institution. Three (4%) patients ultimately went on to use TPN indefinitely and thus were considered to be chronically TPN-dependent. CONCLUSIONS Decompressive PEG insertion is safe and effective at alleviating obstructive symptoms in patients with prolonged postoperative ileus, gut dysmotility, and/or complicated nonmalignant obstruction.