Muhammad A. Jawad

Causes of small bowel obstruction after Roux-en-Y gastric bypass: a review of 2,395 cases at a single institution

AbstractBackgroundnInternal hernia is a relatively common postoperative complication after Roux-en-Y gastric bypass (RYGB) procedure. It has been reported that 1–9xa0% of laparoscopic RYGB patients develop internal herniation through Peterson’s or mesenteric defect. However, a considerable number of patients presenting with possible small bowel obstruction (SBO) after laparoscopic RYGB do not always have internal herniation.PurposeThe aim of our study was to determine the causes of SBO for patients in which both potential internal hernia spaces were closed at the time of the original operation.SettingAcademic Practice, USA.Materials and methodsOf 2,395 patients who underwent laparoscopic RYGB between January 2004 and October 2012, a total of 93 (3.9xa0%) patients were reoperated for possible SBO at our institution. A retrospective review of a prospectively collected database was performed for all patients.ResultsA total of 93 patients had 105 reoperations in the study period, resulting in a reoperation rate for possible SBO of 3.9xa0%. The mean time period between the laparoscopic RYGB and the first 93 reoperations was 20.9xa0±xa018.1xa0months (range 0–100). Eleven patients required secondary reoperations at a mean period of 20.1xa0±xa017.7xa0months (range 0–52) after the first reoperation. Of these 105 reoperations, 29 (27.6xa0%) showed internal herniation at the mesenteric defect (Nxa0=xa023), Peterson’s defect (Nxa0=xa05), and both (Nxa0=xa01). A total of 50 (47.6xa0%) reoperations revealed extensive adhesions causing SBO. Of these 50 cases, 12 revealed adhesions at the jejunojejunostomy, causing it to kink and obstruct. Ten (9.5xa0%) cases showed intussusception of the jejunojejunal anastomosis. Overall, reoperation rate due to internal herniation was 1.1xa0% in our patient population.ConclusionsOur findings indicate a 3.9xa0% reoperation rate for abdominal pain and SBO, and more than 45xa0% of these patients had symptoms secondary to adhesions. Only 1.1xa0% of our laparoscopic RYGB patients developed internal herniation after closure of both internal hernia spaces.

Robotic Roux-en-Y Gastric Bypass, is it Safer than Laparoscopic Bypass?

BackgroundAlong with the development of technology, robotic approach is being performed for laparoscopic Roux-en-Y gastric bypass (LRYGB). Some literatures reported same or better peri-operative outcomes with the robotic procedure. The aim of this study is to compare our experience in robot-assisted LRYGB (RA-LRYGB) with LRYGB in terms of peri-operative outcomes.MethodsFrom January 1, 2012 to April 30, 2014, a total of 270 patients underwent LRYGB by one surgeon at a single institution. Of these, 64 cases were done robotically. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure.ResultsThe 64 RA-LRYGB patients had a mean age of 45.9u2009±u200910.0xa0years (range, 23–67) and a mean preoperative body mass index (BMI) of 48.4u2009±u20097.9xa0kg/m2 (range, 33.8–76.4). The 207 LRYGB patients had a mean age of 45.0u2009±u200910.7xa0years (range, 21–67) and a mean preoperative BMI of 48.4u2009±u20098.1xa0kg/m2 (range, 34.0–80.4). These two groups were clinically comparable. Mean length of hospital stay was 3.0u2009±u20094.1xa0days (range, 1–19) in RA-LRYGB patients, significantly longer than 1.6u2009±u20091.7xa0days (range, 1–17) in LRYGB patients (pu2009<u20090.01). Thirty-day readmission rate was 9.3xa0% (nu2009=u20096) in the RA-LRYGB group and 6.8xa0% (nu2009=u200914) in the LRYGB group. Higher leak rate was noticed in RA-LRYGB patients at 7.8xa0% (nu2009=u20095), compared to 0.5xa0% (nu2009=u20091) in LRYGB patients (pu2009<u20090.01). All the leaks occurred at the pouch level in the RA-LRYGB group, while one leak from the LRYGB group occurred at the gastrojejunal anastomosis site.ConclusionsRobot-assisted Roux-en-Y gastric bypass may result in higher leak rate at the pouch level, when compared to that of laparoscopic procedures.

Safety and Effectiveness of Roux-en-Y Gastric Bypass in Patients Between the Ages of 17 and 19

BackgroundBariatric surgery is becoming more appealing as an option in addressing adolescent obesity. Concerns that may be encountered status postbariatric surgery include complications and failure to lose weight. The aim of our study is to describe safety and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients between the ages of 17 and 19.MethodsA retrospective chart review was completed on LRYGB patients between January 2005 and May 2012. Fifteen patients less than 20xa0years of age were included. One patient was lost to follow-up, and therefore, 14 patients under the age of 20 were matched to 14 patients greater than 20xa0years of age for gender (pu2009>u20090.99), preoperative body mass index (BMI) (pu2009>u20090.96), and follow-up interval (pu2009>u20090.80).ResultsMean postoperative BMI at last follow-up did not show statistical difference between the two (pu2009>u20090.74). Mean percentage of excess weight loss (%EWL) in patients under the age of 20 was 43.1u2009±u200914.6, 70.5u2009±u200917.0, 69.8u2009±u200917.3, and 54.8u2009±u20098.5xa0% at postoperative 6, 12, 24, and 36xa0months, respectively. In patients over the age of 20, mean %EWL was 39.9u2009±u200912.6, 67.0u2009±u200918.6, 60.2u2009±u200911.3, and 56.2u2009±u20096.2xa0%. Both group of patients showed improvement/remission of their comorbid conditions. No statistical difference was present between the two groups in terms of weight loss and comorbidity resolution. Each group had a single patient that required a revision for weight regain.ConclusionLRYGB in younger patients almost the age of 20 is both safe and effective when compared to matched adults in regard to weight loss, comorbid condition, and complications.

Pericardial patch ring Roux-en-Y gastric bypass: a preliminary report.

BackgroundLaparoscopic Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. Failure of weight loss has been reported in 10 to 30xa0% of RYGB patients. Silastic ring RYGB was introduced to minimize failure rate, however, with higher complication rate. The aim of our study is to evaluate the safety of utilizing pericardial patch as a ring on RYGB patients.MethodsBetween March 2010 and June 2011, a total of 189 patients underwent pericardial patch ring RYGB at the Bariatric and Laparoscopy Center. A retrospective review of a prospectively collected database was performed for all pericardial patch ring RYGB patients, noting the outcomes and complications of the procedure.ResultsPericardial patch ring RYGB patients demonstrated a mean percentage of excess weight loss of 57.4xa0% at a mean follow-up of 11xa0months. Out of 164 patients with follow-up, five (3.0xa0%) patients required endoscopic balloon dilation due to dysphagia, abdominal pain, and/or gastric outlet obstruction. All patients did well after the procedure. Three (1.8xa0%) patients underwent diagnostic laparoscopy for abdominal pain. Of these patients, one (0.6xa0%) had dilated and enlarged blind limb, and two (1.2xa0%) patients had partial small bowel obstruction. No patient was readmitted or reoperated due to pericardial patch ring.ConclusionsLonger follow-up is needed to prove the true efficacy of this procedure in reducing weight gain. Pericardial patch ring RYGB seems to be a safe alternative for banded RYGB of other materials.

Routine Gastrostomy Tube Placement in Gastric Bypass Patients: Impact on Length of Stay and 30-Day Readmission Rate

BackgroundLaparoscopic Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. Current average length of hospital stay (LOS) after RYGB is 2–3xa0days and 30-day readmission rate is 8–13xa0%. The aim of our study is to evaluate the effect of routine gastrostomy tube placement in perioperative outcomes of RYGB patients.MethodsBetween January 2008 and December 2010, a total of 840 patients underwent RYGB at our institution. All RYGB patients had gastrostomy tube placed, which was kept for 6xa0weeks. A retrospective review of a prospectively collected database was performed for all RYGB patients, noting the outcomes and complications of the procedure.ResultsAverage LOS in our patient population was 1.1xa0days (range, 1–14xa0days), and 824 (98.3xa0%) patients were discharged on postoperative dayxa01. Readmissions within 30xa0days after the index RYGB was observed in 31 (3.7xa0%) patients. Reasons included abdominal pain (nu2009=u200914), nausea/vomiting (nu2009=u20096), gastrostomy tube-related complications (nu2009=u20095), chest pain (nu2009=u20093), allergic reaction (nu2009=u20091), urinary tract infection (nu2009=u20091), and dehydration (nu2009=u20091). Of these readmitted patients, nine (1.1xa0%) patients required reoperations due to small bowel obstruction (nu2009=u20095), perforated anastomotic ulcer (nu2009=u20091), anastomotic leak (nu2009=u20091), subphrenic abscess (nu2009=u20091), and appendicitis (nu2009=u20091).ConclusionsRoutine gastrostomy tube placement in the gastric remnant at the time of RYGB seems to have contributed to our short LOS and low 30-day readmission rate.

Robot-Assisted Versus Laparoscopic Sleeve Gastrectomy: Learning Curve, Perioperative, and Short-Term Outcomes

BackgroundCurrently, sleeve gastrectomy is most commonly performed laparoscopically. However, robot-assisted approach for sleeve gastrectomy is increasing in number among bariatric surgeons. The aim of our study is to compare perioperative outcomes of robot-assisted (RA-LSG) and laparoscopic sleeve gastrectomy (LSG).MethodsBetween June 2008 and December 2014, 647 patients underwent LSG and RA-LSG at our institution. A retrospective review was performed for 379 LSG and 268 R-LSG patients, noting the outcomes and complications of the procedure.ResultsThe first 100 LSG and RA-LSG cases were separated to reflect the influence of learning curve. Mean length of hospital stay (LOS) was longer in RA-LSG patients at 1.3u2009±u20090.6xa0days (range, 1–4), while it was 1.1u2009±u20090.3xa0days (range, 1–2) in LSG patients. Thirty-day readmission rate was similar in both groups, 5.0xa0% in LSG and 6.0xa0% in RA-LSG group. One mortality (1.0xa0%) occurred in the RA-LSG group. In patients after 100 cases, mean LOS was still longer in RA-LSG patients at 1.7u2009±u20091.8xa0days (range, 1–21), while it was 1.2u2009±u20090.5xa0days (range, 1–5) LSG patients. Thirty-day readmission rate and 30-day reoperation rate did not show a significant difference between the two groups. Overall leak rate was 3.2xa0% (nu2009=u20099) in LSG group, and 1.9xa0% (nu2009=u20095) in RA-LSG group, and the difference was not statistically significant.ConclusionsOur study showed similar 30-day readmission and reoperation rate between LSG and RA-LSG during the learning curve and after the proficiency has been achieved.

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.

Conversions After Sleeve Gastrectomy for Weight Regain: to Single and Double Anastomosis Duodenal Switch and Gastric Bypass at a Single Institution

BackgroundWith the increase in popularity of laparoscopic sleeve gastrectomy (LSG), the number of patients experiencing weight regain has increased as well. This study aims to demonstrate the outcomes of LSG conversions to Roux-en-Y gastric bypass (RYGB), double anastomosis duodenal switch (DS), and single anastomosis duodeno-ileal sleeve (SADI-S) due to weight regain.MethodsA retrospective chart review was performed on 21 patients who underwent a conversion of LSG due to weight regain between March 1, 2013, and April 30, 2017. A longitudinal analysis was performed for the body mass index (BMI) measures, using multilevel model for change.ResultsOf 21 patients, 6 underwent a conversion to RYGB, 9 underwent a conversion to SADI-S, and 6 underwent a conversion to double anastomosis DS. Mean percentage of total weight loss was 16.0% at 6xa0months, 20.1% at 12xa0months, 18.8% at 24xa0months, and 21.8% at 36xa0months after the procedure. The final model suggests that preoperative BMI is the most significant indicator for initial status and the rate of change in BMI. Adjusting for preoperative BMI, type of procedure significantly affected the rate of change in BMI. The rate of decrease was fastest in RYGB patients, adjusting for preoperative BMI. One patient was readmitted 26xa0days after the conversion for pulmonary embolism and intraabdominal hematoma, and no patient required a reoperation within 30xa0days after the conversion.ConclusionConversions of LSG to RYGB, double anastomosis DS, and SADI-S are safe and can provide significant additional weight loss.

Robotic-Assisted Laparoscopic Biliopancreatic Diversion, Vertical Sleeve Gastrectomy with Traditional Roux-en-Y Duodenal Switch

BackgroundAlthough effective, duodenal switch can be a complicated and time-consuming operation for surgeons.PurposeThe purpose of this article is to present our technique of biliopancreatic diversion and vertical sleeve gastrectomy, creating a 150-cm common channel and a 100-cm alimentary limb.Material and MethodsA robot-assisted technique was utilized in creating a biliopancreatic diversion and vertical sleeve gastrectomy.ResultsLaparoscopy was used for marking stitches and then the robot was docked. After creating a window behind the duodenum, sleeve gastrectomy is performed followed by duodeno-ileal anastomosis and ileo-ileal anastomosis.ConclusionWith the adoption of robots and the described technique, it can be easier to be achieved in less time.