Roger de la Torre

Use of Endoscopic Stents to Treat Anastomotic Complications after Bariatric Surgery

BACKGROUND Complications after bariatric surgery often require longterm parenteral nutrition to achieve healing. Recently, endoscopic treatments have become available that provide healing while allowing for oral nutrition. The purpose of this study was to present outcomes of the largest series to date treating staple line complications after bariatric surgery with endoscopic covered stents. STUDY DESIGN A retrospective evaluation was performed of all patients treated for staple line complications after bariatric surgery at a single tertiary care bariatric center. Acute postoperative leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after both gastric bypass and sleeve gastrectomy were included. RESULTS From January 2006 to June 2007, 19 patients (11 with acute leaks, 2 with chronic fistulas, and 6 with strictures) were treated with a total of 34 endoscopic silicone covered stents (23 polyester, 11 metal). Mean followup was 3.6 months. Immediate symptomatic improvement occurred in 90% (91% of acute leaks, 100% of fistulas, and 84% of strictures). Oral feeding was started in 79% of patients immediately after stenting. Resolution of leak or stricture after stent treatment occurred in 16 of 19 patients (84%). Healing of leak, fistula, and stricture occurred at means of 33 days, 46 days, and 7 days, respectively. Three patients (1 with leak, 1 with fistula, and 1 with stricture) had unsuccessful stent treatment. Migration of the stent occurred in 58% of 34 stents placed. Most migration was minimal, but three stents were removed surgically after distal small bowel migration. There was no mortality. CONCLUSIONS Treatment of anastomotic complications after bariatric surgery with endoscopic covered stents allows rapid healing while simultaneously allowing for oral nutrition. The primary morbidity is stent migration.

Laparoscopic Roux-en-Y Gastric Bypass: A Totally Intra-abdominal Approach--Technique and Preliminary Report

Background: Previous descriptions of a laparoscopic Roux-en-Y gastric bypass, using a circular stapler to perform the gastrojejunal anastomosis, have employed the esophagus as a conduit to introduce the anvil of the stapling device into the stomach. The authors believe that the risk of injury to the esophagus, as well as the difficulty in maneuvering the anvil from the pharynx to the proximal part of the stomach, make this technique less than optimal. In other descriptions (in a porcine model) the anvil has been guided into position through a distal gastrotomy by attaching it to a Prolene suture on a straight needle and directing the needle toward a chosen site. Although the authors prefer this method because it avoids potential esophageal injury, they sought a technique that would be even more precise in anvil placement and would avoid pushing a needle across gastric mucosa. Methods: The authors have developed a method that is totally intra-abdominal and does not risk injury to the esophagus. The circular stapler is still used, thus giving a consistent, small opening through the gastrojejunal anastomosis. Results: Over a 1-year period, 49 (of 50) patients underwent laparoscopic Roux-en-Y gastric bypass with the described method. The average body mass index dropped from 42.63 to 34.12 over the first post- operative 3 months, with an average loss in excess body weight of 38.5%. The length of hospitalization following the procedure averaged 3.8 days, and the time to return to work (where applicable) was 11.9 days. Conclusion: This totally intra-abdominal laparoscopic technique is feasible and advantageous.

Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy

BACKGROUND Failure of primary bariatric surgery is frequently due to weight recidivism, intractable gastric reflux, gastrojejunal strictures, fistulas, and malnutrition. Of these patients, 10-60% will undergo reoperative bariatric surgery, depending on the primary procedure performed. Open reoperative approaches for revision to Roux-en-Y gastric bypass (RYGB) have traditionally been advocated secondary to the perceived difficulty and safety with laparoscopic techniques. Few studies have addressed revisions after RYGB. The aim of the present study was to provide our experience regarding the safety, efficacy, and weight loss results of laparoscopic revisional surgery after previous RYGB and sleeve gastrectomy procedures. METHODS A retrospective analysis of patients who underwent laparoscopic revisional bariatric surgery for complications after previous RYGB and sleeve gastrectomy from November 2005 to May 2007 was performed. Technical revisions included isolation and transection of gastrogastric fistulas with partial gastrectomy, sleeve gastrectomy conversion to RYGB, and revision of RYGB. The data collected included the pre- and postoperative body mass index, operative time, blood loss, length of hospital stay, and intraoperative and postoperative complications. RESULTS A total of 26 patients underwent laparoscopic revisional surgery. The primary operations had consisted of RYGB and sleeve gastrectomy. The complications from primary operations included gastrogastric fistulas, refractory gastroesophageal reflux disease, weight recidivism, and gastric outlet obstruction. The mean prerevision body mass index was 42 ± 10 kg/m(2). The average follow-up was 240 days (range 11-476). The average body mass index during follow-up was 37 ± 8 kg/m(2). Laparoscopic revision was successful in all but 1 patient, who required conversion to laparotomy for staple line leak. The average operating room time and estimated blood loss was 131 ± 66 minutes and 70 mL, respectively. The average hospital stay was 6 days. Three patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia. The overall complication rate was 23%, with a major complication rate of 11.5%. No patients died. CONCLUSION Laparoscopic revisional bariatric surgery after previous RYGB and sleeve gastrectomy is technically challenging but compared well in safety and efficacy with the results from open revisional procedures. Intraoperative endoscopy is a key component in performing these procedures.

Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents

BACKGROUND To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en-Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. METHODS A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. RESULTS A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1-6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. CONCLUSION An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en-Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.

Management of Postsurgical Leaks in the Bariatric Patient

Postsurgical leaks after bariatric procedures are a significant cause of morbidity and mortality. They usually arise from anastomotic and staple line failures that are attributed to surgical technique, ischemia, and patient comorbid conditions. Timely diagnosis from subtle clinical clues is the key to appropriate management. Traditional treatment consists of adequate control of the intra-abdominal infection via surgical or percutaneous drainage maneuvers, antibiotics, and nutrition support via parenteral or feeding tube routes. Recently, endoscopically placed covered esophageal stents have been used to exclude the leak site, allowing oral nutrition and speeding healing.

Biomarkers associated with breast cancer are associated with obesity.

BACKGROUND Obesity is linked to the development of postmenopausal breast cancer, and some studies indicate obesity predicts a worse prognosis for premenopausal women who develop the disease. It was our hypothesis that proteins associated with breast cancer would be associated with body mass index (BMI). METHODS We searched our database of women enrolled in breast health translational research trials for information on BMI and markers predictive of breast cancer (basic fibroblast growth factor (bFGF), prostate-specific antigen (PSA), human kallikrein (hK)2, and urinary plasminogen activator (uPA). Information on BMI and one or more nipple aspirate fluid (NAF) or serum biomarkers was available from 382 women. RESULTS In this data set, NAF and serum levels of PSA (nPSA and sPSA), and NAF levels hK2, bFGF and uPA were each associated with pre- and/or postmenopausal breast cancer. sPSA was inversely associated with BMI in both pre- (r=-.56, p=.001) and postmenopausal women (r=-.62, p=.0035) without breast cancer. This association was lost when controlling for plasma volume. In women without breast cancer, NAF bFGF (p=.07, premenopausal subjects) and NAF hK2 (p=.09, postmenopausal subjects) were borderline associated with BMI. In women with breast cancer, nPSA was inversely (r=-.53, p=.049) associated with BMI in premenopausal women and directly associated with BMI in postmenopausal women (r=.37, p=.017). nPSA trended higher in hormone sensitive cancers, especially those that expressed progesterone receptor (p=.059). CONCLUSIONS sPSA was inversely associated with BMI in all pre- and postmenopausal women and specifically in pre- and postmenopausal women without breast cancer. NAF PSA was associated with BMI in pre- and postmenopausal women with breast cancer. Evaluating the change in PSA with changes in weight may provide clues regarding a subjects breast cancer risk.

Long-term outcome after endoscopic stent therapy for complications after bariatric surgery

Although bariatric surgery effectively reduces the mortality risk from obesity-related comorbidities [1, 2], it is associated with a 1–5% risk of anastomotic complications. Anastomotic leaks have traditionally been treated with a combination of drainage with long-term parenteral nutrition or postanastomotic enteral nutrition, allowing the leak to heal. Strictures at the gastrojejunostomy are initially treated with repeated endoscopic dilation, but revisional bariatric surgery is needed for refractory strictures with its associated high complication rate. Chronic fistulas are initially treated conservatively but often need high-risk revisional surgery. Recently, endoscopic covered stents have been used successfully for treatment of anastomotic complications after esophageal resection [3–5]. Case series evaluating stents to treat anastomotic leaks after Roux-enY gastric bypass have shown success [6–9]. However, the numbers of patients enrolled in these studies are small, and only short-term outcomes are reported. The primary aim of this study is to present long-term healing rates after endoscopically placed covered stents in the treatment of various anastomotic complications after bariatric surgery. The secondary aim is to analyze symptom improvement scores, complications, and factors affecting stent migration.

Laparoscopic Repair of Perforated Marginal Ulcer Following Roux-en-Y Gastric Bypass: A Case Series

INTRODUCTION Marginal ulcer perforation is a known complication of Roux-en-Y gastric bypass (RYGB), and laparoscopic repair may be a feasible option minimizing the morbidity associated with a large laparotomy incision. We present our experience with laparoscopic repair of perforated marginal ulcers in patients who have previously undergone RYGB. METHODS A retrospective chart review from August 2005 to April 2007 was performed identifying all patients who underwent laparoscopic repair of perforated marginal ulcer after RYGB at one hospital. The perforation was repaired either by laparoscopic primary suture closure followed by application of an omental patch or by laparoscopic Graham patch without primary suture repair. Operative time, duration of hospitalization, postoperative follow-up, and postoperative complications were recorded. Data are presented as mean ± standard deviation. RESULTS Six patients underwent laparoscopic repair of a perforated marginal ulcer. Operative time was 101.8 ± 50 minutes with a mean hospitalization of 5.3 ± 2.7 days. Follow-up was 6.2 ± 7.5 months. Postoperative complications included 2 patients with nausea and vomiting related to an exposed suture at the gastrojejunostomy, 1 patient with chronic gastritis, and 1 patient developed a stricture at the gastrojejunostomy. CONCLUSIONS We present the largest series to date of laparoscopic repair of perforated marginal ulcers utilizing an omental patch for repair. We demonstrate that a laparoscopic repair can be completed in a reasonable operative time, with minimal postoperative hospitalization, and low associated morbidity. Patients who develop a perforated marginal ulcer after RYGB can be safely and effectively treated with laparoscopic repair with an omental patch.

A suture-based liver retraction method for laparoscopic bariatric procedures: results from a large case series.

BACKGROUND Laparoscopic bariatric surgery requires retraction of the left lobe of the liver to provide adequate operative view and working space. Conventional approaches utilize a mechanical retractor and require additional incision(s), and at times an assistant. OBJECTIVES This study evaluated the safety and efficacy of a suture-based method of liver retraction in a large series of patients undergoing laparoscopic bariatric surgery. This method eliminates the need for a subxiphoid incision for mechanical retraction of the liver. SETTING Two hospitals in the Midwest with a high volume of laparoscopic bariatric cases. METHODS Retrospective chart review identified all patients undergoing bariatric surgery for whom suture-based liver retraction was selected. The left lobe of the liver is lifted, and sutures are placed across the right crus of the diaphragm and were either anchored on the abdominal wall or intraperitoneally to provide static retraction of the left lobe of the liver. RESULTS In all, 487 cases were identified. Patients had a high rate of morbid obesity (83% with body mass index >40 kg/m(2)) and diabetes (34.3%). The most common bariatric procedures were Roux-en-Y gastric banding (39%) and sleeve gastrectomy (24.6%). Overall, 6 injuries to the liver were noted, only 2 of which were related to the suture-based retraction technique. Both injuries involved minor bleeding and were successfully managed during the procedure. The mean number of incisions required was 4.6. CONCLUSIONS Suture-based liver retraction was found to be safe and effective in this large case series of morbidly obese patients. The rate of complications involving the technique was extremely low (.4%).

Device for Safely Closing Trocar Sites in Minimally Invasive Abdominal Surgery

Laparoscopic and robotic surgeries of the abdomen require a trocar to facilitate entry and removal of instrumentation. Some of these trocars are 5mm or less, but some trocars for these surgeries are larger, with 8mm to 15mm trocars commonly used. One of the well-known problems seen in minimally invasive surgery to the abdomen is the resulting defect left in the abdominal wall following removal of the trocars. Occasionally, especially after removal of larger trocars, a defect is left that is large enough to allow omentum or segments of small intestine to become entrapped within the resulting space in the abdominal wall. These trocar site hernias can cause pain, but they also may lead to small bowel obstruction and bowel ischemia or even infarction, perforation and death. The likelihood of a trocar site hernia is increased when the minimally invasive procedure requires removal of an organ or a mass. This often requires dilatation of the trocar site opening.1,2,3Re-operation to reduce and repair trocar site hernias adds significant cost to the healthcare system. Two separate studies report that incidence of trocar site hernias are in the ranges of 0.65%–2.8%4 and 1.5%–1.8%5,6. Based on a 2016 report published by the American Society for Metabolic and Bariatric Surgery (ASMBS), 196,0007 bariatric procedures were performed in 2015. Assuming an average incidence rate of 1.7%, and based on the cost analysis provided by a 2008 case study8, in bariatric surgery alone, it is estimated that the treatment and hospitalization of such hernias adds an additional