Nasser Sakran

Portomesenteric Thrombosis Following Laparoscopic Bariatric Surgery Incidence, Patterns of Clinical Presentation, and Etiology in a Bariatric Patient Population

OBJECTIVE To describe the incidence of, the patterns of clinical presentation of, and the reasons for portomesenteric vein thrombosis among patients who underwent laparoscopic bariatric surgery. DESIGN Retrospective, multicenter study. SETTING Six academic bariatric centers. PATIENTS Morbidly obese patients diagnosed with portomesenteric vein thrombosis following laparoscopic bariatric surgery between January 2007 and June 2012. MAIN OUTCOME MEASURES Clinical presentation, diagnostic measures used, treatments employed, outcome, and hematologic workup of patients. RESULTS Of 5706 patients who underwent laparoscopic bariatric surgery, 17 (0.3%) had portomesenteric vein thrombosis, 16 after sleeve gastrectomy and 1 following adjustable gastric banding. Seven patients were women, the mean age was 38 years, and the mean body mass index was 44.3. The median time to presentation was 10.1 days, and the median time to diagnosis was 11.7 days. New-onset epigastric pain was present in all patients, whereas other signs and symptoms were sporadically found. Computed tomography was performed and was diagnostic in 16 cases. Ultrasonography was used for 9 patients, and positive results were found for 8 of these patients. Patients were treated by anticoagulation with subcutaneous low-molecular-weight heparin (n = 15) or intravenous heparin (n = 2), followed by warfarin sodium. One patient underwent transhepatic portal infusion of streptokinase. Three patients required surgery: laparoscopic splenectomy due to infarct and abscess for 1 patient and laparotomy for 2 patients (with necrotic small-bowl resection for 1 of these patients). There were no deaths. CONCLUSIONS Portomesenteric vein thrombosis is rare after laparoscopic bariatric surgery. Familiarity with this dangerous entity is important. Prompt diagnosis and care, initiated by a high index of suspicion, is crucial.

Gastrobronchial fistula as a complication of bariatric surgery: a series of 6 cases.

Objective: To present a multicenter series of 6 patients who developed gastrobronchial fistula (GBF). GBF is a rare subtype of gastric leaks following bariatric surgery, which is the mainstay of treatment for the obesity pandemic. Methods: We retrospectively identified 6 patients with GBF (out of 2,308 cases performed: 0.2%). One patient had undergone Roux-en-Y gastric bypass, and 5 had a sleeve gastrectomy. Demographics, previous surgeries, clinical presentation, timing of fistula diagnosis, diagnostic and treatment measures employed, and outcome were collected. Results: Four patients were female, the average age and BMI were 42 years and 42.5 kg/m2, respectively. Three patients had previous surgeries (Nissen fundoplication, adjustable gastric banding, and vertical banded gastroplasty). Median time to fistula diagnosis was 40 days (range 15–90 days). Clinical presentation included chronic cough, hemoptysis, dyspnea and fever as well as persistent left pleural effusion or pneumonia. Diagnosis was confirmed by computed tomography in all cases. Two patients were treated nonoperatively, while 4 eventually required surgery for resolution. Left lower lobectomy was necessary in 3 of 4 cases. Concomitant procedures were total gastrectomy in 2 cases and conversion of a sleeve to a gastric bypass in 1 case. Resolution occurred 30 days to 2 years after initial surgery. No mortalities were encountered. Conclusions: GBF is a rare but devastating complication following bariatric surgery. It may develop as a late complication of a chronic upper gastric leak. Surgery is curative although nonoperative management may be warranted in selected cases.

Splenic Abscess after Sleeve Gastrectomy: A Report of Two Cases

Objective: Partial demarcation and infarction of the upper pole of the spleen is not a rare occurrence after laparoscopic sleeve gastrectomy (LSG). However, development of an abscess in the absence of leakage is extremely rare. Case Reports: We present herein two unusual case reports of splenic abscess in patients following LSG.

Probiotics administration following sleeve gastrectomy surgery: A randomized double-blind trial

Background:Probiotics are commonly used after bariatric surgery; however, uncertainty remains regarding their efficacy. Our aim was to compare the effect of probiotics vs placebo on hepatic, inflammatory and clinical outcomes following laparoscopic sleeve gastrectomy (LSG).Methods:This randomized, double-blind, placebo-controlled, trial of 6-month treatment with probiotics (Bio-25; Supherb) vs placebo and 6 months of additional follow-up was conducted among 100 morbidly obese nonalcoholic fatty liver disease (NAFLD) patients who underwent LSG surgery. The primary outcome was a reduction in liver fat content, measured by abdominal ultrasound, and secondary outcomes were improvement of fibrosis, measured by shear-wave elastography, metabolic and inflammatory parameters, anthropometrics and quality of life (QOL). Fecal samples were collected and analyzed for microbial composition.Results:One hundred patients (60% women, mean age of 41.9±9.8 years and body mass index of 42.3±4.7 kg m−2) were randomized, 80% attended the 6-month visit and 77% completed the 12-month follow-up. Fat content and NAFLD remission rate were similarly reduced in the probiotics and placebo groups at 6 months postsurgery (−0.9±0.5 vs −0.7±0.4 score; P=0.059 and 52.5 vs 40%; P=0.262, respectively) and at 12 months postsurgery. Fibrosis, liver-enzymes, C-reactive protein (CRP), leptin and cytokeratin-18 levels were significantly reduced and QOL significantly improved within groups (P⩽0.014 for all), but not between groups (P⩾0.173 for all) at 6 and 12 months postsurgery. Within-sample microbiota diversity (alpha-diversity) increased at 6-month postsurgery compared with baseline in both study arms (P⩽0.008) and decreased again at 12 months postsurgery compared with 6 months postsurgery (P⩽0.004) but did not reach baseline values.Conclusions:Probiotics administration does not improve hepatic, inflammatory and clinical outcomes 6- and 12 months post-LSG.

Different effects of bariatric surgical procedures on dyslipidemia: a registry-based analysis

BACKGROUND The scale and variables linked to bariatric surgerys effect on dyslipidemia have not been conclusive. OBJECTIVE To compare the effect of Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and adjustable gastric banding (LAGB) on dyslipidemia SETTING: National bariatric surgery registry. METHODS Plasma lipids and associated variables were compared at baseline and 1 year (12±4 mo) after surgery for registry patients with dyslipidemia enrolled from June 2013 to August 2014. RESULTS The greatest mean total-cholesterol (TC) reduction was observed post-RYGB, 226.7±26.4 to 181.3±30.9 mg/dL (19.9%, n = 208), followed by post-SG, 227.9±24.4 to 206.7±34.2 mg/dL (8.9%, n = 1515; P<.001). Normal TC levels of below 200 mg/dL were achieved by 76% post-RYGB patients compared with 43.5% post-SG patients (odds ratio [OR] = 6.24, 95% confidence interval [CI]: 3.69-10.53) and 25.6% post-LABG patients (OR = 9.66, 95% CI: 4.11-22.67; P<.01). Although equivalent patterns were observed for low-density-lipoprotein cholesterol (LDL), the levels of high-density-lipoprotein cholesterol (HDL) were most improved post-SG, reaching normal levels in 58.1% of SG male patients versus 39.5% of RYGB male patients (OR = 1.56, 95% CI: 1.04-2.35), (P = .02). The lowering of triglyceride levels by approximately 75% was comparable after SG and RYGB procedures. The type of surgery was the strongest independent predictor for all lipid level improvements or remissions. Male sex was an independent predictor for LDL normalization only (OR = 1.88, 95% CI: 1.24-2.85). Excess weight loss offered no meaningful prediction for lipid improvement (OR = 1.01-1.03). CONCLUSION Particular types of bariatric surgeries had different effects on dyslipidemia, independent of weight loss. Overall, the RYGB achieved the biggest reduction in plasma lipids (TC and LDL), although SG did affect HDL. Our results could aid in the decision-making process regarding the most appropriate procedure for patients with dyslipidemia.

Computed Tomographic Diagnosis of Incarcerated Meckel’s Diverticulum in a Patient with Bilateral Spigelian Hernia

IntroductionSpigelian hernia is an uncommon abdominal wall hernia occurring through the linea semilunaris located near the lateral border of the rectus abdominis muscle.Case reportWe report an extremely rare case of incarcerated Meckel’s diverticulum within a Spigelian hernia diagnosed by multidetector computed tomography.

Obesity-related acetylcholinesterase elevation is reversed following laparoscopic sleeve gastrectomy

BackgroundImpaired sympathetic/parasympathetic response, expressed by elevated Acetylcholinesterase (AChE) is associated with obesity, metabolic syndrome and inflammation. However, the association between morbid obesity and AChE and the changes in cholinergic tone following bariatric laparoscopic sleeve gastrectomy (LSG) surgery-induced weight reduction were never analyzed.MethodsTwo studies are presented; the first (the “apparently healthy cohort”) was a cross-sectional study and the second (the “LSG cohort”) was a prospective-cohort study with 12 months of follow-up. The “apparently healthy cohort” included 1450 apparently healthy participants who volunteered to the Tel-Aviv Medical Center Inflammation Survey (TAMCIS) during a routine annual checkup visit. The “LSG cohort” included 77 morbid obese patients before and at 3, 6, and 12 months following LSG surgery. Main outcomes included anthropometric measurements, Hemoglobin A1c (HbA1C), serum AChE, insulin test and Homeostasis Model Assessment (HOMA).ResultsAmong the TAMCIS participants, serum AChE activity increased with BMI in a dose-dependent manner until it reached a peak level at BMI of 30–35 kg/m², followed by a plateau. Following LSG, a significant decrease in AChE activity between baseline and 12 months post-surgery was found for men, but not for women (−122.2 ± 135.3, P < 0.001 vs. −21.8 ± 120.5, P = 0.258 nmol substrate hydrolyzed/min per ml, respectively). The reduction in AChE activity was negatively correlated with %excess weight loss (EWL) and positively correlated with %body fat reduction at 12 months post-surgery among women (r = −0.329, P = 0.034 and r = 0.350, P = 0.023, respectively). In men, AChE activity reduction was positively correlated with the HOMA reduction (r = 0.358, P = 0.048).ConclusionsObesity-related AChE resistance phenotype may be reversed following LSG and correlates with metabolic outcomes. Further long-term studies will be needed to validate and evaluate the beneficial effect of AChE reduction post bariatric surgery.

Conversion for failed adjustable gastric banding warrants hiatal scrutiny for hiatal hernia

BackgroundFailure or complications following laparoscopic adjustable gastric banding (LAGB) may necessitate band removal and conversional surgery. Band position and band-induced chronic vomiting create ideal conditions for de novo hiatal hernia (HH) formation. HH presence impedes and complicates conversional surgery by obscuring crucial anatomical landmarks and hindering precise gastric sleeve or pouch formation. The aim of this study was to evaluate the incidence of a HH in patients with an LAGB undergoing conversion compared to patients undergoing primary bariatric surgery (BS).MethodsRetrospective review of consecutive BS performed between 2010 and 2015. Data collected included demographics, anthropometrics, comorbidities, previous BS, preoperative and intra-operative HH detection, operation time, perioperative complications and length of hospital stay.ResultsDuring the study period, 2843 patients (36% males) underwent BS. Of these, 2615 patients (92%) were “primary” (no previous BS—control group), 197 (7%) had a previous LAGB (study group), and 31 (1%) had a different previous BS and were excluded. Reasons for conversion included weight regain, band intolerance and band-related complications. Mean age and body mass index were similar between the study and the control groups. HH was preoperatively diagnosed by upper gastrointestinal (UGI) fluoroscopy in 9.1% and 9.0% of the LAGB and control groups (p = NS), respectively. However, HH was detected intra-operatively in 20.3% and 7.3%, respectively (p < 0.0001).ConclusionsPreoperative diagnosis of a HH by UGI fluoroscopy for patients who have undergone LAGB is unreliable. Intra-operative hiatal exploration is highly recommended in all cases of conversional BS after LAGB.

The Question of Bile Gastro-Esophageal Reflux

Although it was the main reason to abandon Mason’s loop gastric bypass, the mini-gastric bypass (MGB) anatomical configuration makes esophageal bile reflux highly implausible. However, controversy remains regarding the long-term theoretical risk of subsequent biliary reflux and its possible complications following MGB. According to the current literature, symptomatic gastric and/or esophageal bile reflux and reoperations after MGB due to “intractable” bile reflux are relatively rare.

Laparoscopic Repair of a Large Paraesophageal Hernia with Migration of the Stomach into the Mediastinum Creating an Upside-Down Stomach

Upside-down stomach is a relatively rare type of a large paraesophageal hernia characterized by the migration of the stomach into the posterior mediastinum. Upside-down stomach is prone to severe complications and therefore surgery is recommended even in asymptomatic patients. A 62-year-old male presented with frequent abdominal pain with nausea and vomiting that persisted for one year. The patient was obese with fatty liver and was treated medically for gastroesophageal reflux disease (GERD) for 4 years. On upper gastrointestinal CT study a level-IV paraesophageal hernia was detected with upside-down stomach, and he was referred for elective surgery. Laparoscopic surgery included reduction of the stomach into the abdominal cavity followed by dissection of the paraesophageal membrane and hernia sac. The hiatal defect was closed using a wound closure device and nonabsorbable sutures. The defect closure was reinforced using Physiomesh tucked anteriorly and sutured posteriorly to the diaphragm. Follow-up was uneventful and the patient is free of complaints. The results of this surgical intervention support previous reports that laparoscopic repair with the use of biological mesh in the setting of large paraesophageal hernia should be favorably considered.