Faculty Bibliography

Background: Venous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days. Objectives: Evaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis. Setting: University Hospital. Methods: Between 2012"“2018, SG patients were discharged on extended chemoprophylaxis for patients deemed "high-risk" for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018"“2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed. Results: A total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m², respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively. Conclusions: Routine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.

BACKGROUND:Portomesenteric vein thrombosis (PMVT) may occur after laparoscopic sleeve gastrectomy (LSG). Previous studies have shown that PMVT patients may have undiagnosed thrombophilia. We recently changed our practice to check thrombophilia panel in every LSG patient preoperatively. OBJECTIVES/OBJECTIVE:To estimate the thrombophilia prevalence in patients seeking LSG, and determine if extended chemoprophylaxis post LSG reduces PMVT. SETTINGS/METHODS:University hospital. METHODS:Thrombophilia panels were drawn on every patient seeking LSG after July 2018 at 2 high-volume accredited bariatric surgery centers. A positive panel included factor VIII >150%; protein C <70%; protein S <55%; antithrombin III <83%; and activated protein C resistance <2.13. Patients with a positive panel were discharged on extended chemoprophylaxis. PMVT rates and bleeding occurrences were recorded for LSG patients from August 2018 to March 2019 and were compared with a historic cohort of LSG performed from January 2014 to July 2018. RESULTS:, respectively. Of the cohort, 52.4% (563/1075) had positive thrombophilia panel, including factor VIII elevation (91.5%), antithrombin III deficiency (6.0%), protein S deficiency (1.1%), protein C deficiency (.9%), and activated protein C resistance (.5%). Between January 2014 and July 2018, 13 PMVT were diagnosed among 4228 LSG (.3%) and there were 17 bleeding occurrences (.4%). After August 2018, one PMVT was diagnosed among 745 LSG (.1%) and there were 5 bleeding occurrences (.6%). CONCLUSIONS:The estimated thrombophilia prevalence in patients seeking LSG is 52.4%. The majority (91.5%) of these patients have factor VIII elevation. Extended prophylaxis may decrease PMVT postLSG.

BACKGROUND:. At 3-year follow-up, surgery was very effective in T2D remission; furthermore, in the surgical group, those with a higher baseline soluble receptor for advanced glycation end products had a lower postoperative BMI. OBJECTIVES/OBJECTIVE:To provide long-term follow-up of this initial patient cohort. SETTING/METHODS:University Hospital. METHODS:Retrospective chart review was performed of the initial patient cohort. Patients lost to follow-up were systematically contacted to return to clinic for a follow-up visit. Data were compared using 2-sample t test, Fisher's exact test, or analysis of variance when applicable. RESULTS:; P = .007), and higher percent weight loss (21.4% versus 10.3%; P = .025). Baseline soluble receptor for advanced glycation end products was not associated with long-term outcomes. CONCLUSIONS:remains effective long term. Baseline soluble receptor for advanced glycation end products are most likely predictive of early outcomes only.

Bariatric surgery is the most effective treatment for morbid obesity. Availability of different procedures with low complication rates, performed through a minimally invasive approach, have caused profound positive effect on patient's quality of life and has led to their worldwide, rapid expansion of the field. The laparoscopic revolution has introduced the concept of lowering more and more the treatments' invasiveness, leading to a change in the researchers' mentality. They are now constantly looking for reducing patients' discomfort through new methodologies and devices: aim of this review is to provide an in-depth analysis of the most promising, innovative procedures offering an alternative approach to "classic" laparoscopic procedures. They are described from their original development phases to the most recent experimental and clinical evidence. This review will discuss as well their future perspectives, and includes endoluminal techniques and/or procedures based on alternative concepts, all representing an appealing alternative to surgical approach. We conducted a MEDLINE for articles, clinical trials, and a patent search relating to the minimally invasive management of obesity, excluding intragastric balloons, SILS, and NOTES, and we selected 77 articles. Results are reported for each procedure/device, and discussed both in these paragraphs and in the final, general discussion. The concept of minimally invasive procedures continues to change and evolve over time with novel technologies emerging every year.

Background: Portomesenteric vein thrombosis (PMVT) is a known complication after laparoscopic sleeve gastrectomy (LSG). Previous studies have indicated that many of these patients may have an undiagnosed thrombophilia. We recently changed our practice to check thrombophilia panel on every patient preoperatively undergoing LSG. The purpose of this study is to 1) estimate the prevalence of thrombophilia in patients seeking LSG and 2) determine if extended chemoprophylaxis post-LSG reduces PMVT.
Method(s): Thrombophilia panels were drawn on every patient seeking LSG after July 2018 at two high-volume bariatric surgery centers. A positive thrombophilia panel included: Factor VIII>150%, Protein C<70%, Protein S<55%, and Anti-thrombin<83%. Patients with positive thrombophilia panel were discharged on extended chemoprophylaxis. PMVT rates for all LSG performed from Jan 2014 thru July 2018 (no routine preop thrombophilia panel) were compared to PMVT rates after July thru March 2019 (routine preop thrombophilia panel).
Result(s): 1075 patients seeking LSG had thrombophilia panel checked preoperatively. The cohort was 83% female, 84% Hispanic and 15% non-Hispanic African American; mean age and BMI were 39.2 years and 43 kg/m², respectively. 577/1075 (54%) had abnormal thrombophilia panel preoperatively, including Factor VIII elevation (89.4%), Anti-thrombin III deficiency (5.9%), Protein S deficiency (2.9%), and Protein C deficiency (2.5%). Between January 2014 and July 2018, 18 PMVT were diagnosed among 4228 LSG (0.4%). After July 2018, 1 PMVT was diagnosed among 745 LSG (0.1%) who had thrombophilia panel checked preoperatively.
Conclusion(s): The estimated prevalence of thrombophilia is 54% in this patient population. Extended prophylaxis may decrease PMVT post-LSG.
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Background: We previously conducted a randomized controlled trial comparing diabetes surgery to intensive medical weight management (MWM) to treat patients with type 2 diabetes (T2DM) and Body Mass Index (BMI) 30-35 kg/m². At 3 year follow-up, we found that surgery was highly effective in T2DM remission and that the soluble form of RAGE (receptor for advanced glycation end-products) may be an adequate diabetes biomarker that may help determine which patient population would benefit most from surgery. The purpose of this study is to provide longer-term (5-year) follow-up of this initial patient cohort.
Method(s): Retrospective chart review was performed of the initial patient cohort. Demographic data from the initial cohort included baseline weight, glycated hemoglobin (HbA1c) as well as medications. Repeated measures linear models were used to model weight loss and change in HBA1c.
Result(s): Originally, 57 patients with T2DM and BMI 30-35 were randomized to surgery (bypass, sleeve or band based on patient preference; n=30) vs. MWM (n=27). At baseline, mean BMI was 32.6 kg/m² and mean HbA1c was 7.8. At 5 year follow-up, the surgery group continued to have lower HbA1c (6.58 vs. 7.99) and lower BMI (27 kg/m² vs. 29.9 kg/m²) vs. the non-surgical group. At 3 years, in the surgical group, those with a higher baseline sRAGE had a lower post-op BMI.
Conclusion(s): Diabetes surgery in T2DM patients with BMI 30-35 kg/m² remains effective up to 5 years. Higher baseline sRAGE may predict success with surgery.
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INTRODUCTION: Anastomotic gastric adenocarcinoma (GAC) following distal gastrectomy Billroth II for peptic ulcer disease (PUD) has long been recognized but remains poorly studied. CASE DESCRIPTION/METHODS: A 65-year-old male with history of PUD status post Billroth II in 1991 presented with multiple episodes of melena and abdominal pain. EGD revealed friable gastric mucosa with oozing ulcers on the gastric side of the gastrojejunal anastomosis (GJA) (Figure 1a-c) and severe bile reflux. Stomach biopsies were negative for H. pylori or other pathology. Patient was subsequently admitted four more times that year for similar symptoms, each time presenting with symptomatic anemia that resolves with therapy, and EGD showing superficial erosions near the GJA. It was suspected however, that the initial biopsies were likely taken from areas far from the actively bleeding sites. Therefore, the GI team insisted on an outpatient EGD when the patient was asymptomatic to accurately investigate the GJA. After multiple missed appointments, he had an outpatient EGD (Figure 1d) with biopsies of the friable mucosa positive for GAC, and eventually underwent Roux-en-Y gastrectomy with esophagojejunostomy. Biopsy of the mesenteric nodules confirmed the diagnosis of moderately differentiated Stage IIIA GAC. Chemoradiation therapy was initiated, but patient left against medical advice and ended up in hospice care eight months later. DISCUSSION: We present a patient with persistent bleeding ulcers and symptomatic anemia 25 years after a Billroth II procedure, who despite multiple endoscopic evaluations with stomach biopsies, was not diagnosed on time. Eventually, the correct diagnosis of Stage III primary GAC was made after an outpatient EGD with targeted biopsies of the area associated with recurrent bleeding. Given the negative biopsies, the persistent gastric ulcers were thought to be complications of Billroth II with a short limb leading to bile reflux, or due to patient's poor compliance and follow up. However, it was recognized that the patient had a higher risk of GAC as he was 15-20 years after Billroth II, and more importantly, that the inpatient EGD biopsies were not of the actively bleeding area of interest. Our patient presented after a long asymptomatic interval with symptoms initially misinterpreted as benign. It is therefore imperative to maintain a high suspicion of gastric malignancy for these patients to encourage earlier diagnosis. (Figure Presented)

INTRODUCTION: Bariatric surgery has become a common therapeutic approach to obesity. However, bariatric procedures may affect bowel habits due to changes in dietary intake as well as altered anatomy. To date, few studies have evaluated the impact of bariatric surgery on post-operative constipation. The aim of this study is to determine if patients experience a greater rate of constipation after bariatric surgery compared to non-bariatric controls.
METHOD(S): A retrospective chart review at New York Langone Hospital (NYU) was performed on 160 bariatric surgery patients who had surgery in the year 2012 and 160 control patients with BMI < 30 kg/m2 seen in primary care in 2012. Reports of constipation were recorded up until November 2018. Exclusion criteria included those with inflammatory bowel disease or hereditary colorectal cancer syndromes prior to age 50. The primary outcome was diagnosis of post-operative constipation. Secondary outcomes included rates of constipation according to surgical procedure. Presence of constipation was recorded if listed on the problem list or if medications for constipation were prescribed. Logistic regression and chi-squared testing was used to assess differences in groups.
RESULT(S): Table 1 shows patient characteristics of the study population. The average age of bariatric surgery patients was 64.1 years compared to 69.8 in the control group. Overall, 20% of bariatric patients were diagnosed with constipation compared to 15% of controls (P = 0.239). Constipation rates post-bariatric surgery were 17.9% in lap band, 20.6% in sleeve gastrectomy, and 7.1% in gastric bypass patients (P = 0.256). A logistic regression controlling for age, sex, and Charlson co-morbidity index was performed between controls and post-surgery subjects. This revealed no significant difference in rates of constipation between the two groups (OR 1.158, 95% CI 0.790 - 1.696 P-value = 0.45). There was, however, a significant difference in constipation rates between the bariatric group pre-surgery (13.8%) and post-surgery (17.5%) (P = < 0.001) (Table 2).
CONCLUSION(S): Bariatric surgery patients experience significantly higher rates of constipation after surgery compared to prior to surgery, but similar rates to controls without obesity. Constipation impairs quality of life and is associated with significant health care costs. Further studies investigating the mechanisms underlying this increase in constipation after bariatric surgery and effective measures to treat it are warranted. (Figure Presented)

Perforated duodenal ulcer following RYGB is an unusual clinical situation that may be a diagnostic challenge. Only 23 cases have previously been reported. We present five cases. The hallmark of visceral perforation, namely pneumoperitoneum, was not seen in three of the four cases that underwent cross sectional imaging. This is perhaps due to the altered anatomy of the RYGB that excludes air from the duodenum. Our cases had more free fluid than expected. The bariatric surgeon should not wait for free intraperitoneal air to suspect duodenal perforation after RYGB.