Faculty Bibliography

BACKGROUND:When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE:We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN/METHODS:We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING/METHODS:Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS/METHODS:A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION/METHODS:Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES/METHODS:The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS:There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = -2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted P < 0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (P = 0.034). CONCLUSION/CONCLUSIONS:Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION/BACKGROUND:NCT02452060.

BACKGROUND:With obesity continuing as a global epidemic and therapeutic technologies advancing, several novel endoscopic and minimally invasive interventions will likely become available as treatment options. With improved technologies and different treatment strategies, as well as different patient populations being targeted, there will be greater application in the treatment armamentarium of specialists dedicated to treating obesity. We sought to review the existing technology and provide a review. METHODS:Literature review was carried out for endoscopic and minimally invasive devices. Some of these products are not FDA approved, so limited data are available in their review. RESULTS:A summary of the device and data currently available on weight loss and safety profile is provided. Several products are in clinical trials or will be soon. Some of the technology has limited data and companies will be submitting their results for FDA evaluation. CONCLUSIONS:The obesity epidemic and associated weight-related diseases represent a tremendous burden to health care practitioners. As such, a multi-modal and progressive approach, with data and outcomes examined, is likely the best and most comprehensive method to care for these patients. SAGES endorses the benefits of minimally invasive and endoscopic approaches in the treatment of obesity and its related co-morbidities.

BACKGROUND:Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE:To investigate long-term results of salvage gastric banding. SETTING/METHODS:University Hospital, New York, United States. METHODS:Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS:with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION/CONCLUSIONS:The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.

Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a common and effective form of bariatric weight loss surgery. However, a subset of patients will fail to achieve the expected total body weight loss (TBWL) greater than 20% after 12 months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. Although alternative procedural interventions exist for operative revision after suboptimal RYGB weight loss, laparoscopic adjustable gastric banding (LAGB) provides an option with short operative time, low morbidity, and effective results. We have previously demonstrated that short-term (12-month), and mid-term (24-month) weight loss is achievable with LAGB for failed RYGB. The objective of this study is to report the long term 5 year outcomes of LAGB after RYGB failure. Methods and Procedures: A retrospective review of prospectively collected data before and after RYGB when available, and before and after revision with LAGB was performed. The data included weight, height, body mass index, gender, race, age, operative time, length of stay, postoperative complications, and percentage of total body weight loss. Results: A total of 182 patients (81.3% female, 18.7% male) were included in this study. The mean age of patients undergoing LAGB after RYGB was 47+/-9.98 years old. The majority of patients (98.4%) underwent gastric band placement laparoscopically, with 2 patients requiring conversion to an open procedure, and 1 planned open approach. The mean preoperative weight was 319+/-64 lbs and BMI of 53+/-10 kg/m² before RYGB. After RYGB, patients experienced a mean %TBWL of 16+/-11%, had a weight of 264+/-50 lbs, and a BMI of 43+/-7 kg/m² before undergoing LAGB an average of 9 years after their first bariatric procedure. At the time of 5 year follow up after LAGB the patients had a %TBWL of 35+/-13%, weight of 201.9+/-46 lbs, and had a BMI of 33+/-7 kg/m². The mean operative time was 73+/-34 minutes and 85% of patients had a hospital length of stay less than 24 hours. Conclusion: The results of our study have shown that LABG had good long term data as a revi-sionary procedure for weight loss failure after RYGB. Patients experienced a satisfactory amount of total body weight loss with reduction in BMI and had a short operative time and length of stay

BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

Aim: The literature supports comparable safety profiles in regard to performing one vs. two stage revisional conversions of laparoscopic adjustable gastric bands to sleeve gastrectomies. In this discussion, we compare weight loss differences between one and two stage gastric band removal to sleeve gastrectomy procedures. The reasoning behind this discussion is the question: can an appropriately sized sleeve be created at the same time as gastric band removal (assuming scar tissue and tissue swelling), and can that sleeve permit adequate weight loss? Methods: This is a retrospective review of patients who underwent gastric band removal and subsequent sleeve gastrectomies between 2008 and 2016. We reviewed each patient's BMI at the time of the revisional sleeve gastrectomy and compared the BMI reduction (BMIR) and percentage total body weight loss (%BWL) after one year between patients undergoing a concurrent gastric band removal and sleeve gastrectomy vs. those undergoing a gastric band removal with an interval sleeve gastrectomy (3 or more months after band removal). Results: Between 2008 and 2016 there were 259 patients who underwent surgery converting a gastric band to a sleeve gastrectomy (191 one stage, 68 two stage). We compared the weight loss parameters for those following up at one year for both one stage and two stage conversions (104 one stage, 38 two stage). One stage conversions exhibited a 16.95% total body weight loss while two stage conversions exhibited a 17.95% total body weight loss (p=0.08). BMI reduction was also reviewed at one year showing 7.49 for one stage and 7.95 for two stage procedures (p=0.81). Conclusions: The safety of one vs. two stage laparoscopic adjustable gastric band conversion to sleeve gastrectomy has been supported in the literature. We demonstrate that there is no statistical difference in weight loss, after one year, between patients having their conversion at the same time (one stage) or in an interval manner (two stage). Therefore, there appears to be no weight loss benefit favoring a one vs. two stage procedure-thus leaving the choice up to surgeon's level of operative comfort and preference

The management of refractory gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy can be challenging. After conservative measures with medical management, dietary changes, and behavioral modification have failed, revision surgery can be considered. Preoperative evaluation should include radiographic and endoscopic studies to assess for any possible anatomic or functional etiologies. We present a case of a patient with refractory GERD after laparoscopic sleeve gastrectomy who was found to have a large sliding hiatal hernia. She was successfully treated with a hiatal hernia repair and conversion to roux-en-y gastric bypass