Faculty Bibliography

Objectives: Over the last decade there has been a sharp increase in the use of laparoscopic sleeve gastrectomy (LSG) relative to Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric band (LAGB). We sought to further examine national trends in bariatric surgery and determine whether the changes in bariatric procedure use over time, particularly the growth in LSG, were uniformly represented among clinical subgroups in the US. Methods: Patients with a body mass index (BMI) >35kg/m² who underwent bariatric surgery from 2005-2012 in the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database were identified. Procedure use, year of surgery, and patient population were evaluated. Logistic regression was used to analyze yearly trends in LSG versus RYGB use among clinically relevant subgroups. Results: We identified 100,304 patients who underwent bariatric procedures between 2005 and 2012 in the NSQIP database. Laparoscopic RYGB was the most common bariatric surgery type performed each year, but had a decreasing trend (75% of cases in 2005 vs. 53.2% in 2012) [Figure 1]. From 2010 to 2012, LSG increased substantially from 9.5% to 34.4% of bariatric procedures performed per year, while LAGB decreased from 28.8% to 9.7%. Over this period, minority patients represented an increasing proportion of those who underwent LSG compared to Caucasian patients. The proportion of LSG patients who were elderly (>65 years), superobese (BMI >50kg/m²), diabetic, high-risk, and ASA class 4-5 also rose, but to a significantly lesser degree than patients <65 years, BMI <50kg/m², non-diabetics, low-risk patients, and ASA class 1-3, respectively [Table 1]. In multiple logistic regression, factors independently associated with having LSG over RYGB in 2012 were age <65 (OR=1.58, 95% CI=[1.32-1.89], p<0.0001]), minority race (OR=1.30, 95% CI=[1.21-1.40], p<0.0001]), non-diabetic (OR=1.51, 95% CI=[1.39-1.63], p<0.0001), low-risk (OR=1.38, 95% CI=[1.27-1.50], p<0.0001]), ASA class 1-3 (OR=1.25, 95% CI= [1.01-1.55], p<0.0037), and BMI <50kg/m2 (OR=1.25, 95% CI=[1.16-1.35], p<0.0001]). Conclusions: LSG use has grown substantially over the last decade, but to a greater extent among certain patient subgroups. Although LSG was developed as the first stage of a two-stage biliopancreatic diversion-duodenal switch for high-risk patients, LSG is being performed on patients who are younger with less risk, whereas RYGB is targeted to those with more severe cases of obesity, surgical risk, and diabetes. Further studies will be necessary to clarify whether this approach reflects surgical preference or has been influenced by patient preferences

Background: Nutritional deficiencies due to bariatric surgery have been known to occur after malabsorptive procedures, but can also occur after primarily restrictive procedures such as laparoscopic sleeve gastrectomy (LSG). A deficiency in vitamin B1 (thiamine), secondary to intractable vomiting, decreased intake, or malabsorption can result in serious disorders such as Wernicke's encephalopathy. To date, only a few cases of severe vitamin B1 deficiency leading to Wernicke's encephalopathy after restrictive bariatric procedures have been reported. We herein present a case of Wernicke's encephalopathy following LSG. Methods: A 43-year-old superobese (BMI 53 kg/m²) male underwent an uncomplicated LSG. Postoperatively, he developed hypersalivation, dysphagia, and intractable emesis. Symptoms persisted and at 10 weeks, he was found to have short-term memory loss, depression, and nystagmus. Wernicke's encephalopathy was suspected and MRI of the brain confirmed the diagnosis with bilateral enhancement of the mammillary bodies. Vitamin B1 level was low at 47 nmol/L. Results: The patient was treated with IV thiamine and intramuscular B12 injection, and discharged on hospital day 4 with PO vitamin supplementation. Two months after discharge, his thiamine levels are within normal limits and symptoms have resolved. Conclusions: Micronutrient deficiencies following a restrictive procedure such as LSG are rare. Patients with postoperative hyperemesis have increased susceptibility to develop thiamine deficiency and therefore neurologic monitoring and early prophylactic thiamine supplementation should be considered

BACKGROUND: Marginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers. METHODS: Data from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed. RESULTS: Twelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU. CONCLUSION: Patients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.

Background: Laparoscopic revisional surgery after previous open gastric bypass can be technically challenging. This video demonstrates the laparoscopic repair of an anastomotic diverticulum - a rare complication of Roux-en-Y gastric bypass. Methods: The initial bypass operation was performed in an open technique, resulting in significant adhesions. After adhesiolysis, the diverticulum was resected and the dilated pouch was revised with preservation of the prior gastrojejunal anastomosis. Results: The patient tolerated the procedure well. There were no complications with the surgery and the patient was sent home on postoperative day 1, tolerating a liquid diet. Postoperative esophagram confirmed normal post Roux-en-Y gastric bypass anatomy. On posteroperative day 35, the patient is doing well and tolerating a regular diet. Conclusions: This video demonstrates the repair of a late and rare complication of gastric bypass, namely gastrojejunal anastomotic diverticulum. Despite significant adhesions and complex postoperative surgical anatomy, the case was completed entirely laparoscopically

Background: Although smoking is thought to increase surgical complications, there is little scientific data on the effect of smoking on outcomes after bariatric surgery, specifically the laparoscopic sleeve gastrectomy (LSG). This study's objective was to determine the effect of smoking on outcomes after LSG. Methods: In the 2010-2012 NSQIP database, patients with BMI >35kg/m² who underwent elective LSG were identified. Primary outcome was overall 30-day complication rate and secondary outcomes included major postoperative complications. Results: Of 10,882 LSG patients, 1,098 (10.1%) were smokers. Mean BMI was 46.2 kg/m². Smokers and non-smokers were similar in baseline characteristics, but smokers were younger (40.8 vs. 44.4 years, p<0.001). There was no difference in the overall rate of 30-day complications between smokers and non-smokers (8.5 vs. 8.2, p=0.710). Specific postoperative complications, including wound infection, intraabdominal infection, sepsis, renal injury, myocardial infarction, cardiac arrest, deep vein thrombosis, pulmonary embolism, reoperation, and prolonged length of stay did not differ between groups. After correcting for relevant covariates in a logistic regression, smoking did not increase the odds of 30-day complications (OR 1.03, 95%CI=[0.74-1.43], p=0.871). Smokers did, however, have an increased risk of unplanned reintubation (OR 3.942, 95%CI=[1.13=13.79], p=0.032). Conclusions: Smoking does not impact the overall rate of 30-day complications after LSG, but it is associated with an increased risk of unplanned reintubation. Surgeons should take this into account when counseling patients and determining their policy for smoking cessation prior to elective bariatric surgery

Background: Mesenteric venous thrombosis (MVT) is a rare and potentially lethal complication of laparoscopic bariatric surgery. We present the diagnosis, management and surveillance of three MVT cases after laparoscopic sleeve gastrectomy (LSG). Methods: Three morbidly obese (BMIs 40kg/m²-52kg/m²) women between the ages 33-50 years presented with symptoms of abdominal pain after uncomplicated LSG. Symptoms presented between postoperative day 12 and 25. All patients underwent computed tomography (CT) scans and were found to have mesenteric vein thrombosis. Treatment modalities varied between warfarin anticoagulation in two patients and rivaroxaban in the third, who was resistant to heparin. One patient was positive for the prothrombin gene mutation, but hypercoagulability workup was negative for the other two patients. Results: Repeat imaging was available for two patients at 4 and 18 months postoperatively. At 4 months, one patient developed cavernous transformation of the portal vein and upper abdominal varices. Repeat imaging in another patient demonstrated chronic SMV thrombosis at 18 months. Conclusions: MVT can present with nonspecific abdominal symptoms after LSG. The mainstay of treatment is anticoagulation, but the duration, especially for chronic MVT, is unclear. On surveillance, two patients have chronic MVT despite anticoagulation and negative hematologic workup, which can lead to portal hypertension and its sequelae. Additional research is needed to define the incidence, symptomatology, and treatment algorithms for this rare but serious complication

BACKGROUND: The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice. METHODS: A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery. RESULTS: There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20 % (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group. CONCLUSIONS: Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Aims: One of the known complications of gastric bypass is the development of marginal ulcers. Without appropriate surveillance and management, these ulcers can have severe consequences, including stricture and perforation. This video presents a patient with these complications, resulting in the need for revisional surgery. Methods: The case is a 53 year-old woman with morbid obesity who underwent Roux-en- Y gastric bypass 6.5 years ago. She developed recurrent, perforated marginal ulcers requiring operative intervention prior to her presentation. Repeat endoscopy did not reveal any residual ulcers, and preoperative esophagram showed a dilated gastric pouch. The patient underwent resection of the strictured anastomosis and recreation of the gastrojejunostomy, as highlighted in the video. Results: An esophagram on the first postoperative day showed a markedly smaller gastric pouch without leak or obstruction. The patient was able to tolerated thin liquids, and was discharged to home on postoperative day 3. At her most recent office visit 2 months postoperatively, she has recovered well and is tolerating a diet. Her current BMI is 25. Conclusions: Marginal ulceration can be seen after Roux-en-Y gastric bypass surgery, and if left untreated, can result in major morbidity including stomal stricture and gastric perforation. Laparoscopic revision of the gastrojejunostomy can be performed safely and effectively

Introduction: Staple line leak is the most feared complication after sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak, however the utility of these tests is controversial. The 2012 International Sleeve Gastrectomy Expert Panel failed to reach a consensus about whether routine intraoperative leak tests should be performed. Additionally, these tests are not benign - they introduce increased instrumentation, with reports of nasogastric tubes causing esophageal perforation, as well as increased costs in the form of resource utilization. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. Methods and Procedures: A retrospective cohort study was designed using a prospectively-collected database of seven bariatric surgeons from two institutions. 1,257 consecutive patients who underwent sleeve gastrectomies between March 2012 and June 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, patient demographics, comorbidity, presence or absence of intraoperative leak test, result of leak test, and type of test. The primary outcome was leak rate between the leak test (LT) group and the non-leak test (NLT) group. SPSS-22 was used for univariate and multivariate analyses. Results: Of the 1,257 sleeve gastrectomy cases, most (99.68 %) were laparoscopic, except for two (0.16 %) open and two (0.16 %) converted cases. 1,164 (92.6 %) patients had routine intraoperative leak tests performed; there were no positive intraoperative leak tests in the entire cohort. 93 patients (7.4 %) did not have intraoperative leak tests performed. Thirteen (1 %) patients developed staple line leaks, with no difference in leak rate between the LT and NLT groups (1 % vs. 1.1 %, p = 1.000). There were some baseline differences between the groups, however (Table 1). After adjusting for these differences and other possible confounders with binary logistic regression, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 11.3 days postoperatively (range = [1,35]), with only two leaks presenting during the index admission. Of those two, one patient with a leak seen on postoperative day 1 esophagram underwent a repeat leak test during diagnostic laparoscopy, which was negative. Despite suture reinforcement, the leak persisted and the patient eventually required conversion to gastric bypass. Conclusion: Intraoperative leak testing has no correlation with postoperative leak occurrence after laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak. (Table Presented)