Faculty Bibliography

Background: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. Methods: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. Results: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen"™s defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen"™s and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P =.019), conversion to exploratory laparotomy (P =.005), and resection of small bowel (P <.001) were independent risk factors for increased LOS. Conclusion: The most common location of IH after RYGB is Petersen"™s defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

BACKGROUND:Evidence shows that 14.2% of opioid-naive patients have long-term opioid dependence after bariatric surgery. Enhanced recovery after surgery (ERAS) protocols are widely used in bariatric surgery, while bariatric surgery targeting opioid prescriptions (BSTOP) protocols were recently introduced. We will investigate the combined impact of ERAS and BSTOP protocols after bariatric surgery. METHODS:We conducted a retrospective review for patients who underwent either a sleeve gastrectomy or Roux-en-Y gastric bypass at a tertiary care center. Pre-intervention and post-intervention data were compared. Primary outcomes were length of stay (LOS), 30-day readmission, 30-day complications, and discharge on opioids. Multivariate Poisson regression with robust standard error was used to analyze LOS. RESULTS:There was no significant difference in 30-day emergency room visits (3.3% vs. 4.0%; p value = 0.631), 30-day readmission (4.4% vs. 5.4%; p value = 0.577) or 30-day complication rate (4.2% vs. 6.4%; p value = 0.199). LOS was significantly lower in the post-intervention group; mean (interquartile range) 2 (1-2) days vs. 1 (1-2) day, p value < 0.001. On multivariate analysis, the post-intervention group had 0.74 (95% confidence interval 0.65-0.85; p value < 0.001) times lower LOS as compared to pre-intervention group. Patients with DM had a significantly longer LOS (relative risk: 1.22; p = 0.018). No other covariates were associated with LOS (p value < 0.05 for all). BSTOP analysis found a significant difference between the two groups. Discharge on opioids decreased from 40.6% pre-intervention to 7.1% post-intervention. CONCLUSION:ERAS and BSTOP protocols reduced length of stay and opioid need at discharge without an increase in complication or readmission rates.

COVID-19, a novel respiratory viral illness, has spread globally and led to over 111 million cases worldwide. Most commonly, patients present with respiratory symptoms, and those with increased severity progress to acute hypoxic respiratory failure. Additionally, a portion of patients are noted to have coagulopathy and are considered to be at an increased risk for thromboembolic events. In this article, we present a unique case of a patient with severe abdominal pain in the setting of COVID-19 pneumonia and community acquired Clostridium difficile, found to have superior mesenteric artery thrombosis requiring exploratory laparotomy, thrombectomy and small bowel resection.

Background and Objectives/UNASSIGNED:Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data. Methods/UNASSIGNED:Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day). Results/UNASSIGNED:During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement. Conclusion/UNASSIGNED:Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Background: Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-y gastric bypass (RNY), known colloquially as "band-over-pouch" has become an option despite a dearth of critically analyzed long-term data.
Method(s): Our prospectively-maintained database was retrospectively reviewed for patients who underwent band-over-pouch at our MBSAQIP Center of Excellence in a 15-year period ending February 2019. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and >30-day).
Result(s): During the period, of 4,614 bariatric procedures performed, 42 were band-over-pouch with 39 (93%) being women. Overall, the mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447) and mean BMI 42.4 (range 26-75). Co-morbidities included: hypertension (n=31; 74%), diabetes (n=27; 64%), obstructive sleep apnea (n=26; 62%), gastroesophageal reflux disease (n=26; 62%), and osteoarthritis (n=25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-10). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and 4 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1anastomotic ulcer), 6-year (1 LAGB explant and RNY revision), and 8-year (1 LAGB erosion). Two 5-year mortalities occurred (4.8%); both in association with hospitalization for chronic illness and malnutrition. Both erosions were successfully treated surgically.
Conclusion(s): Band-over-pouch warrants further analysis before widespread adoption as a revisional procedure.
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Background: Gastrocutaneous fistula after gastric bypass is a rare complication. Causes include iatrogenic, traumatic or inflammatory etiologies. Pain and wound complications are debilitating. Multiple approaches exist including percutaneous, endoscopic, and surgical options. Endoscopic approaches involve clipping and fistula plugs and stenting to seal and exclude the fistula.
Method(s): We present a case of a 75-year-old woman with a history of open non-divided gastric bypass 19 years prior that presented with a chronic draining intercostal wound. This started after a thoracoscopic lung and rib resection that was complicated by an infected wound requiring debridement. Surgical history includes splenectomy, abdominoplasty, and ventral herniorrhaphy. The diagnosis was confirmed by fistulogram, which revealed filling of the excluded stomach. Endoscopic approach was not feasible due to the location. Despite multiple abdominal surgeries, a minimally invasive approach was feasible. Access was gained via optical trocar insertion into the right upper quadrant. Additional access ports were placed in the right flank. Extensive adhesive disease was encountered and dissected sharply. The fistula was identified in the left upper quadrant and with great care the tract was dissected circumferentially and sharply divided. The portion of the excluded stomach with the fistula was resected with a linear stapler. The overlying abdominal wall was debrided and packed.
Result(s): The patient had a normal upper GI and was discharged home with local wound care after tolerating a diet on post-operative day 4.
Conclusion(s): A minimally invasive surgical approach is feasible to manage chronic gastrocutaneous fistula in the setting of multiple prior surgeries.
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Management of abdominal pain in a pregnant patient with a history of Roux-en-Y gastric bypass presents unique challenges. A misdiagnosis or delay in management can result in lethal maternal-fetal outcomes. We present a 30-year-old woman at 21 weeks of pregnancy presented with abdominal pain. She had a history of laparoscopic Roux-en-Y gastric bypass performed 3 years earlier. The clinical examination was remarkable for epigastric pain and tenderness. The vital signs and laboratory examinations were unremarkable. The CT scan was suggestive of an internal hernia. On an exploratory laparoscopy, the distal common small bowel was found to be herniating through the jejunojejunostomy mesenteric defect, causing intestinal obstruction with dilatation of the Roux limb and the biliopancreatic limb. The internal hernia was reduced, and no bowel resection was required. The mesenteric defect was closed with 3-0 silk sutures in a continuous fashion. The patient was discharged after 3 days and delivered a healthy baby at 40 weeks of gestation.

Splenic rupture following colonoscopy is rare, first reported in 1974, with incidence of 1-21/100,000. It is critical to anticipate splenic trauma during colonoscopy as one of the causes of abdominal pain after colonoscopy especially when located in the left upper quadrant or left shoulder. Postoperative adhesions is a predisposing factor for splenic injury, and management is either operative or nonoperative, based on hemodynamic stability and/or extravasation which can be seen on contrast-enhanced CT scan of the abdomen. We present a case of a splenic rupture after colonoscopy in a patient with splenocolic adhesions, requiring splenectomy as definite treatment.