Usha K. Coblijn

Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?

BACKGROUND Roux-Y Gastric Bypass is a frequently used technique in bariatric surgery. Postoperative anatomy is altered by exclusion of the stomach, which makes this organ inaccessible for future esophagogastroduodenoscopy (EGD). The value of preoperative assessment of the stomach is unclear. Some institutions choose to investigate the future remnant stomach by EGD, others do not. Aim of the present study is to quantify the yield of preoperative EGD in our institution. METHODS Patients, planned for primary laparoscopic Roux-Y Gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy from December 2007 until August 2012, were screened by EGD in advance. Results of EGD and patient characteristics were retrospectively analyzed and categorized according to a classification system based on intervention needed. RESULTS 523 patients (122 male, 401 female, mean age 44.3 years, average BMI 46.6) underwent preoperative EGD. In 257 patients (48.9%) no abnormality was found (group A), 117 patients (17.2%) had abnormalities without treatment consequences (B1), 84 patients (of the 326 tested [comment #1, reviewer #1, 26.8%] were H. Pylori positive (B2), in 75 (14.3%) treatment with proton pump inhibitors was required (B3), 6 (1.1%) required follow up EGD before surgery (C). For1 patient (0.2%) the operation was canceled because preoperative EGD presented with Barretts esophagus with carcinoma (D). When all abnormalities were taken into account, baselines did show a significant difference for age, gender and reflux symptoms. CONCLUSION Standard preoperative assessment by EGD in patients who are planned for bariatric surgery is not indicated. The number needed to screen to find clinically significant abnormalities is high.

Faecal immunochemical test accuracy in patients referred for surveillance colonoscopy: a multi-centre cohort study

BackgroundGiven the increasing burden on colonoscopy capacity, it has been suggested that faecal immunochemical test (FIT) results could guide surveillance colonoscopy intervals. Against this background, we have evaluated the test accuracy of single and double FIT sampling to detect colorectal cancer (CRC) and/or advanced adenomas in an asymptomatic colonoscopy-controlled high-risk population.MethodsCohort study of asymptomatic high-risk patients (personal history of adenomas/CRC or family history of CRC), who provided one or two FITs before elective colonoscopy. Test accuracy of FIT for detection of CRC and advanced adenomas was determined (cut-off level 50 ng/ml).Results1,041 patients provided a FIT (516 personal history of adenomas, 172 personal history of CRC and 353 family history of CRC). Five CRCs (0.5%) and 101 advanced adenomas (9.7%) were detected by colonoscopy. Single FIT sampling resulted in a sensitivity, specificity, PPV and NPV for CRC of 80%, 89%, 3% and 99.9%, respectively, and for advanced adenoma of 28%, 91%, 24% and 92%, respectively. Double FIT sampling did not result in a significantly higher sensitivity for advanced neoplasia. Simulation of multiple screening rounds indicated that sensitivity of FIT for advanced adenoma could reach 81% after 5 screening rounds.ConclusionsIn once-only FIT sampling before surveillance colonoscopy, 70% of advanced neoplasia were missed. A simulation approach indicates that multiple screening rounds may be more promising in detecting advanced neoplasia and could potentially alleviate endoscopic burden.

The influence of prophylactic proton pump inhibitor treatment on the development of symptomatic marginal ulceration in Roux-en-Y gastric bypass patients: a historic cohort study.

BACKGROUND Marginal ulceration at the gastrojejunostomy is a serious complication after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) and occurs in 1%-16% of patients. Proton pump inhibitors (PPIs) might lower the occurrence of these ulcers. OBJECTIVES The aim of the present study was to evaluate the effect of 6 months prophylactic usage of PPIs on the development of marginal ulceration and compare this with a historic patient control group. SETTING A single institution cohort at a bariatric center of excellence, The Sint Lucas Andreas Zienkenhuis, Amsterdam METHODS A consecutive database of patients who underwent LRYGB from November 2007 to September 2012 in a single institution was retrospectively reviewed. From August 2011, patients received a standard dose of pantozol 40 mg once daily directly postoperatively for 6 months. No standard PPI prophylaxis was administered before August 2011, and the patients not using PPIs in this historic cohort served as the control group. RESULTS A total of 610 patients underwent LRYGB, of which 128 patients (21.0%) underwent revisional surgery. Postoperative PPIs were administered in the intervention group of 337 patients, compared with the historic control group consisting of 273 patients. Six patients (1.2%) who received postoperative PPIs versus 20 patients (7.3 %) in the historic control group developed marginal ulceration (P = .001). Patients using proton pump inhibitors developed fewer gastrointestinal complaints postoperatively (P< .001). CONCLUSIONS Routine usage of PPIs reduced the occurrence of marginal ulceration after LRYGB.

Evaluation of the obesity surgery mortality risk score for the prediction of postoperative complications after primary and revisional laparoscopic Roux-en-Y gastric bypass.

BACKGROUND The Obesity Surgery Mortality Risk Score (OS-MRS) is a validated instrument for mortality risk prediction in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures classifying patients into low risk (class A), intermediate risk (class B), and high risk (class C). OBJECTIVES The primary aim of this study was to evaluate the accuracy of the OS-MRS in predicting postoperative complications after LRYGB. Secondarily, the postoperative complication rate between primary and revisional LRYGB was systematically analyzed. SETTING The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands. METHODS The OS-MRS was applied to a consecutive database of patients who underwent LRYGB from November 2007 onwards. Postoperative complications were scored according to the Clavien-Dindo classification. Revisional LRYGB was separately analyzed. RESULTS LRYGB was performed in 1667 patients either as a primary (81.5%) or revisional (18.5%) procedure. The majority (n = 1371, 82.2%) were female, mean age 44.6 (standard deviation 14.4) years and mean body mass index 44.2 (6.5) kg/m2. Nine hundred and four (54.2%) were OS-MRS class A, 642 class B (38.5%), and 121 (7.3%) class C. Complications occurred in 143 (10.5%) and 44 (14.2%) patients after primary and revisional surgery, respectively. In both primary and revisional LRYGB, there was no association between complications and the OS-MRS classification. Subanalysis comparing primary with revisional LRYGB found a significant association between revisional surgery and the development of severe complications (Clavien-Dindo≥3) (P = .003) and mortality (P = .017). CONCLUSION The OS-MRS was not an accurate predictor for postoperative complications in patients who underwent primary or revisional LRYGB. As in other studies, revisional surgery is an independent risk factor for the development of severe complications.

Persistent moderate or severe obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass: which patients?

BACKGROUND Patients with severe obesity and obstructive sleep apnea (OSA) might decide to undergo bariatric surgery to improve this disease or, more specifically, to become independent of continuous positive airway pressure (CPAP) therapy, which is generally indicated in case of moderate and severe OSA. Knowledge of this topic is important for patient education on expectations of surgical outcome. OBJECTIVES To evaluate the prevalence and phenotypes of patients with persistent moderate to severe OSA after bariatric surgery. SETTING Obesity Center Amsterdam, Amsterdam, the Netherlands. METHODS Patients who underwent a laparoscopic Roux-en-Y gastric bypass, had a preoperative apnea-hypopnea index (AHI)≥15/hr, and of whom a follow-up AHI/hr was available were included. RESULTS Out of 437 patients, 205 underwent pre- and postoperative polysomnography; 232 (53.1%) were lost to follow-up. Median AHI was 32.3/hr (range, 15-138) and mean body mass index was 46 (standard deviation 7.2) kg/m2. A postoperative AHI<15/hr was achieved in 152 patients (74.1%), whereas 53 (25.9%) still had moderate or severe disease 8.6 (standard deviation 4.8) months postoperatively. Predictive factors for persistent moderate to severe disease were age≥50 years, preoperative AHI≥30/hr, excess weight loss (EWL)<60%, and hypertension (area under the curve: .772). CONCLUSION After bariatric surgery, around three quarters of the moderate to severe OSA patients had no or mild OSA, whereas one quarter (25.9%) still had moderate to severe OSA. Age≥50 years, preoperative AHI≥30/hr, EWL<60%, and hypertension were predictive factors for this persistent postoperative AHI≥15/hr.

Influence of continuous positive airway pressure on postoperative leakage in bariatric surgery

BACKGROUND Obstructive sleep apnea (OSA) affects two third of morbidly obese individuals undergoing bariatric surgery. Perioperative usage of continuous positive airway pressure (CPAP) is advised for moderately and severe OSA to avoid respiratory failure and cardiac events. CPAP increases the air pressure in the upper airway, but also may elevate the air pressure in the esophagus and stomach. Concern exists that this predisposes to mechanical stress resulting in suture or staple line disruption (further referred to as suture line disruption). OBJECTIVES To evaluate whether perioperative CPAP usage is associated with an increased risk of suture line disruption after bariatric surgery. SETTING Obesity Center Amsterdam, OLVG-west, Amsterdam, the Netherlands. METHODS All patients who underwent bariatric surgery including a suture line were eligible for inclusion. Only patients with information regarding OSA severity as defined by the apnea-hypopnea-index and postoperative CPAP usage were included. RESULTS From November 2007 to August 2016, postoperative CPAP status was documented in 2135 patients: 497 (23.3%) used CPAP postoperatively, whereas 1638 (76.7%) used no CPAP. Mean body mass index was 44.1 kg/m2 (standard deviation 6.6). Suture line disruption occurred in 25 patients (1.2%). The leakage rate was not associated with CPAP usage (8 [1.6%] in CPAP group versus 17 [1%] in non-CPAP group, P = .300). CPAP was no risk factor for suture line disruption in multivariable analysis as well. CONCLUSION Postoperative CPAP does not appear to increase the risk of suture line disruption in bariatric surgery. CPAP is recommended in all patients with moderate or severe OSA who undergo bariatric surgery.

Patients’ preferences for information in bariatric surgery

BACKGROUND The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision. OBJECTIVE To investigate the bariatric surgery patients preferences regarding information provision in bariatric surgery. SETTING A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands. METHODS All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences. RESULTS Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations-for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery. CONCLUSION Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened.

Response to: "Letter to the Editor: Trocar Site Hernia Prevention in Laparoscopic Bariatric Surgery".

Dear Sir, Thank you for the kind compliments and sharing your view on this subject. I completely agree with your statement that we should aim to reduce the complication rate in bariatric surgery to zero. We found an incidence of trocar port hernias of 0.5 % in our own series which was similar to the pooled bariatric literature. Interestingly, our literature analysis showed an unexpected inverse association between primary closure of trocar ports and the incidence of trocar port herniation. It is well-known that the risk of trocar port herniation is higher for trocars ≥10 mm, and we always close these ports in the general patient population. The metaanalysis which supports this statement consists of many different surgical procedures (i.e., laparoscopic cholecystectomy, colectomy, and reflux surgery) in mainly nonobese patients [1]. We believe that bariatric procedures have less risk of herniation because (1) the trocars are placed high in the upper abdominal area where a fatty omentum shields the trocar ports, (2) the trocar tract is longer compared with non-obese patients, and (3) the tract is more oblique compared with non-obese patients. We believe that these factors have a role in the lower incidence of trocar port hernias in the bariatric patient. The results of your experience with Surgicel and the omental plug are quite impressive and you have managed to reduce the incidence nearly to zero with relatively easy interventions. However, we do have some issues. We do not think that it is economically viable to implant Surgicel in 99.5 % of the patients for nothing since they will never develop a trocar port hernia. In other words, we do not think it is justified to routinely use such an expensive product with a NNTof more than 200 to prevent one hernia. This is presumably also the reason why you switched to the omental plug since this is a less expensive alternative. Regarding the plug, we also have some issues. You cite an experimental study in which subcutaneous fat is successfully transplanted from one location to another in rabbit. But omental fat is quite different from subcutaneous fat [2]. We are very concerned about fat necrosis. For instance, in our experience with incarcerated abdominal hernias with the omentum in the hernia sac, we often find necrotic omentum and resect this. Why should the fate of your devascularized omental pedicle be different? And what about harvest complications such as omental bleeding during dissection? What about added operative time? Unfortunately, it will be difficult to statistically prove if the proposed interventions are associated with a reduced incidence of trocar port hernias because a hernia itself occurs seldom. Perhaps your incidence would stay just as low if you omitted closure? We would have to design very large randomized trials to prove these interventions. After the presentation of our data at IFSO 2014 in Montreal, we had a show of hand to find out who routinely closes the fascia. Approximately 50 % of the bariatric surgeons in the room routinely closed the ≥10-mm port. The only thing our study and the bariatric literature shows is that omitting the closure of the ≥10-mm port results in a very low incidence of trocar port hernias in these patients. Lowering this percentage even more is important but will be difficult to prove. Sincerely, * Usha K. Coblijn usha.coblijn@gmail.com

707 Is Esophago-Gastro-Duodenoscopy Prior to Roux-en-Y Gastric Bypass Mandatory?

Surgical resection for benign subepithelial tumors near the gastroesophageal junction is difficult, often leading to esophagectomy. Here we demonstrate the feasibility of a novel technique of dual endoscopic resection using retroflexed standard adult upper endoscope and second smaller caliber (baby) endoscope to resect benign GE junction leiomyomas (26 cm size) in four patients. Maneuvering the small caliber endoscope allowed offaxis retraction of the mass while the adult endoscope was used to carry out the dissection from the submucosal tissue. Our experience highlights the feasibility of this minimally invasive approach by enabling triangulation using endoscopic tools.