Paresh C. Shah

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUND Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. METHODS The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. RESULTS A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. CONCLUSIONS Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Abnormal glucose tolerance testing after gastric bypass

BACKGROUND Symptoms secondary to dumping have been suggested to help patients refrain from simple carbohydrate ingestion after Roux-en-Y gastric bypass (RYGB). During follow-up examinations, we noted many patients with weight regain complaining of fatigue shortly after eating. Thus, we decided to study the glucose tolerance test (GTT) results in a cohort of post-RYGB patients. METHODS A total of 63 RYGB patients, >6 months postoperatively, were studied with a GTT and measurement of insulin levels. The mean age was 48.5 ± 10.8 years, mean preoperative body mass index was 49.0 ± 6.5 kg/m(2), mean percentage of excess body mass index lost was 64.5% ± 29.0%, mean weight regain at follow-up was 11.6 ± 12.4 lb, and mean follow-up period was 47.9 months. RESULTS Of the 63 patients, 49 had abnormal GTT results. Of the 63 patients, 6 were diabetic; however, only 1 of these patients had an elevated fasting glucose level. All 6 patients were diabetic preoperatively. Of the 63 patients, 43 had evidence of reactive hypoglycemia at 1-2 hours after the glucose load. Of these patients, 22 had a maximum/minimum glucose ratio >3:1, including 7 with a ratio >4:1. CONCLUSION The results of the present study have demonstrated that an abnormal GTT result is a common finding after RYGB. Reactive hypoglycemia was found in 43 of 63 patients, with insulin values that do not support nesidioblastosis. It is our hypothesis, that rather than preventing simple carbohydrate ingestion, the induced hypoglycemia that occurs might contribute to weight regain and maladaptive eating in certain post-RYGB patients.

917 Laparoscopic Pancreas Sparing Segmental Resection of the Distal Duodenum for GIST

Background: Duodenal neuroendocrine tumors are rare and few studies exist to guide surgical management. Endoscopic mucosal resection (EMR), local duodenal resection (LR), and pancreaticoduodenectomy (PD) are typically performed as primary treatment. This study identifies factors associated with recurrence after resection. Methods: A retrospective, single institution review was performed between 1987 and 2011 on patients with a pathologic diagnosis of duodenal neuroendocrine tumor. Biopsy and surgical specimens were independently reviewed by a pathologist. Tumor grade was assigned based on WHO 2010 criteria (KI-67 and/or mitoses per high power field). Results: Seventy-seven patients with a median age of 60 had resectable duodenal neuroendocrine tumors. Based on pathologic review, there were 9 somatostatinomas, 18 gastrinomas, and 49 not otherwise specified. In the entire group, 12 underwent EMR, 35 had LR, and 30 underwent PD (Table). Tumors were graded as low (77%), intermediate (10%), or high (13%). Positive margins for EMR, LR, and PD were identified in 66%, 29% and 3%, respectively. Median follow-up was 27 months. The 3 year recurrence-free survival (RFS) rate was 83% and there were no differences in RFS between the three different treatment groups. Tumors were smaller in the EMR group (p= 0.005) and more likely to have a positive margin compared to the LR and PD group (p,0.001). In all patients, RFS was better in low grade tumors as compared to those that were high or intermediate (p=0.04). Negative margin status and negative lymph nodes were not associated with better RFS. Morbidity after EMR, LR, and PD was 0%, 24%, and 41% respectively. Conclusions: EMR, LR, and PD are all effective treatment approaches for duodenal neuroendocrine tumors. Tumor grade is associated with recurrence-free survival but not lymph node or margin status. When feasible, a less aggressive surgical approach to treat duodenal neuroendocrine tumors should be considered. Table I