Faculty Bibliography

Background: Though the pathogenesis of polycystic ovarian syndrome (PCOS) is incompletely understood, it has been linked to obesity, metabolic syndrome and insulin resistance. The NIH suggests that patients with two of the following: oligo/anovulation, hyperandrogenism and polycystic ovaries on ultrasound, meet the Rotterdam criteria for diagnosis of PCOS.1 The incidence of PCOS is 8% in the general female population and is suspected to be much higher in individuals with obesity as the majority of these patients are undiagnosed. Though not sufficient for diagnosis, oligo/amenorrhea is an important component of the condition and PCOS should be suspected in these patients as the majority of PCOS patients first present with oligomenorrhea. Bariatric surgery has been shown to correct menstrual irregularity and androgen levels in these individuals, but there exists a dearth of literature examining weight loss in women with PCOS compared to those without this diagnosis. Objectives: The objective of this study is to determine whether a difference exists in weight loss following bariatric surgery in patients with PCOS, in patients with menstrual irregularity alone and in patients with no reported menstrual irregularity. Setting: University Hospital. Method: Our institutional database was queried for premeno-pausal women o50 years old who had bariatric surgery between 01/2012-04/2015. Information regarding type of surgery was obtained for each patient. These patients were divided into those who self-reported PCOS, those who reported menstrual irregularity and those who reported neither. Preoperative weight and height were collected and BMI was calculated. Weights were measured at time periods: 30 days (20-40 days were accepted), 90 days (60-120 were accepted), 180 days (121-240 days were accepted), 360 days (270-450 days were accepted) and 720 days (630-810 days were accepted) following surgery. Percent weight loss, change in BMI and percent excess BMI lost was calculated for each of these time periods and the means for each group were obtained. Analysis of variance (ANOVA) was run and p-values were obtained for each time period. Results: 119 patients with PCOS (7.48%), 278 with menstrual irregularity (17.5%) and 1193 with neither (75.0%) underwent bariatric surgery during the time period. Of these, approximately 10% underwent gastric band, 66% underwent sleeve gastrectomy and 24% underwent Roux-en-Y gastric bypass. Starting BMI was 42.83/41.73/42.33 for these groups, respectively (p=.25). Table 1 shows the mean change in BMI, percentage weight loss and change in excess BMI for each group at 30/90/180/360/720 days following surgery. The p values were obtained and are all found to be 44.05 indicating no statistically significant difference between the three groups. Conclusions: There was no difference in weight loss between patients with a diagnosis of PCOS, those with menstrual irregularity, and those without menstrual irregularity in the 2 years following bariatric surgery. Given that patients with PCOS are at higher risk of obesity related complications such as type 2 diabetes and dyslipidemia than those without PCOS, this is an encouraging result as it illustrates the efficacy of bariatric surgery for weight loss in the PCOS cohort. We look forward to further research to clarify the true incidence of PCOS in individuals with obesity as the high incidence of menstrual irregularity in our population leads us to suspect a substantially higher incidence of PCOS than is diagnosed

Background: Rates of obesity are increasing rapidly among young patients and nonsurgical methods of treating this epidemic are largely ineffective in this population. Bariatric surgery has proved to be safe and effective even in prepubertal children for weight loss and resolution of obesity associated comorbidities such as diabetes. However, these benefits have to be weighed against the risks of bariatric surgery including operative complications and post-operative micronutrient deficiencies. There is a scarcity of literature examining weight loss over time associated with bariatric surgery in young patients as compared to their older counterparts. Objective: The objective of this study is to determine whether a difference exists in weight loss following bariatric surgery in female patients who are less than or equal to 25 years of age and those greater than 25 years of age at the time of bariatric surgery. Setting: University Hospital Methods: Our institutional database was queried for premenopau-sal women o50 years old who had bariatric surgery between 01/2012-04/2015. Information regarding type of surgery was obtained for each patient. These patients were divided into two groups, those less than or equal to 25 years of age and those greater than 25 years of age at the time of bariatric surgery. Preoperative weight and height were collected and BMI was calculated. Weights were measured at time periods: 30 days (20-40 days were accepted), 90 days (60-120 were accepted), 180 days (121-240 days were accepted), 360 days (270-450 days were accepted) and 720 days (630-810 days were accepted) following surgery. Percent weight loss, change in BMI and percent excess BMI lost was calculated for each of these time periods and the means for each group were obtained. A t-test was run and p-values were obtained for each time period, with p values o 0.05 considered as statistically significant. Results: 253 patients r25 years old (15.9%) and 1337 patients 425 years old (84.1%) underwent bariatric surgery during this time period. Of these, approximately 10% underwent gastric band, 66% underwent sleeve gastrectomy and 24% underwent Roux-en-Y gastric bypass. Initial BMI was 43.86/41.97 (po.0001) for these groups, respectively. Table 1 shows the mean change in BMI, percentage weight loss and change in excess BMI for each group at 30/90/180/360/720 days following surgery. Figure 1 shows the change in BMI in these two groups over time. BMI was similar for these two groups at 30, 90 and 180 days (p =.23,.45,.12). However, after 180 days, the two groups diverge and the difference in BMI becomes statistically significant at 360 and 720 days (p=.0083,.0304), with the younger patients experiencing greater weight loss over time. A similar pattern is observed in the % weight loss and the change in excess BMI between the younger and older groups at these time points (figure 2 and 3). Complications requiring re-admission, including infection, small bowel obstruction, and dehydration, were similar in both groups (5.14% in r25 years vs. 6.96% in 425 years). Conclusion: Though both groups had the same initial rates of weight loss, the change in BMI, change in excess BMI and % weight loss for the two groups began to diverge after 6 months postoperatively. The younger cohort continued to lose weight, whereas the older cohort not only plateaued but actually regained some of the weight that had been lost at 2 years. Though a notable limitation to this study is that we only included premenopausal females, this patient population accounts for the majority of bariatric operations so we believe it is a valuable cohort to examine. We conclude that bariatric surgery is more effective for weight loss in younger patients when compared to their older counterparts. These surprising results suggest that patients should be encouraged to undergo bariatric surgery at a younger age and not to delay their surgeries until they are older, as younger patients have greater and more sustained weight loss associated with bariatric procedures. We look forward to future research examining long-term weight loss, rates of complications, and resolution of obesity-related disorders in this population

BACKGROUND: Patients with type 2 diabetes (T2D) and body mass index (BMI)<35 may benefit from metabolic surgery. The soluble form of the receptor for advanced glycation end products (sRAGE) may identify patients at greater chance for T2D remission. OBJECTIVES: To study long-term outcomes of patients with T2D and BMI 30-35 treated with metabolic surgery or medical weight management (MWM) and search for predictors of T2D remission. SETTING: University METHODS: Retrospective review of the original cohort, including patients who crossed over from MWM to surgery. Repeated-measures linear models were used to model weight loss (%WL), change in glycated hemoglobin (HbA1C) and association with baseline sRAGE. RESULTS: Fifty-seven patients with T2D and BMI 30-35 were originally randomly assigned to metabolic surgery versus MWM. Mean BMI and HbA1C was 32.6% and 7.8%, respectively. A total of 30 patients underwent surgery (19 sleeves, 8 bypasses, 3 bands). Three-year follow-up in the surgery group and MWM group was 75% and 86%, respectively. Surgery resulted in higher T2D remission (63% versus 0%; P<.001) and lower HbA1C (6.9% versus 8.4%; P<.001) for up to 3 years. There was no difference in %WL in those with versus those without T2D remission (21.7% versus 20.6%, P = .771), suggesting that additional mechanisms other than %WL play an important role for the studied outcome. Higher baseline sRAGE was associated with greater change in HbA1C and greater %WL after surgery (P< .001). CONCLUSION: Metabolic surgery was effective in promoting remission of T2D in 63% of patients with BMI 30-35; higher baseline sRAGE predicted T2D remission with surgery. Larger-scale randomly assigned trials are needed in this patient population.

BACKGROUND: Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS: A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS: Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score >/=9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS: Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

Laparoscopic sleeve gastrectomy (LSG) is rapidly becoming one of the most commonly performed bariatric surgical procedures. With the increase in frequency of this procedure, surgeons should be knowledgeable about its complications and anesthesiologists need to be familiar with the intraoperative technique. This video presents the case of an intraoperative transection of an orogastric tube during LSG, and its subsequent operative and postoperative management

BACKGROUND: Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. METHODS: A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 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, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. RESULTS: A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8 %), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7 %) cases, while 221 (14.3 %) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1 %) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1 %, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. CONCLUSION: Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

BACKGROUND: Many insurance companies require a medical weight management (MWM) program as a prerequisite for approval for bariatric surgery. There is debate regarding the benefit of this requirement. The objective of this study is to assess the effect of insurance-mandated MWM programs on weight loss outcomes in our bariatric surgery population. OBJECTIVE: To assess the effect of insurance-mandated MWM programs on weight loss outcomes in our bariatric surgery population. SETTING: University. METHODS: A retrospective review of all bariatric surgery cases performed between 2009 and 2013 was conducted. Patients were stratified by payor mix based on whether the insurance company required MWM. To control for differences between groups, a bucket matching algorithm was used to match patients based on gender, age, body mass index (BMI), and surgery type (sleeve gastrectomy, gastric bypass, or gastric band). A repeated-measures regression model was created to estimate percent excess weight loss, percent excess BMI loss, and percent total weight loss. RESULTS: A total of 1432 bariatric surgery patients were reviewed. The bucket-matching algorithm resulted in 560 patients for final analysis. Mean age and BMI were 41 years and 43 kg/m2, respectively, and 91% were female. The regression model found no significant differences in weight loss outcomes between the MWM group and the comparison group at 1 year and 2 years-percent total weight loss: 21.3% [95% confidence interval [CI] 20.6%-22.1%] versus 20.2% [95%CI 19.7%-20.6%) at 1 year and 23.4% [95%CI 22.6%-24.3%] versus 21.5% [95%CI 21.0%-22.0%] at 2 years. CONCLUSION: There was no difference in weight loss outcomes up to 2 years in patients who required insurance-mandated MWM programs. Longer-term studies are needed to determine the benefit of this insurance requirement.

Aims: Leaks after laparoscopic sleeve gastrectomy (LSG) often present after discharge from the hospital, making it difficult to diagnose leak in the early postoperative period. This study evaluates preoperative, intraoperative, and postoperative factors in their association with leaks after LSG. Methods: A retrospective case-controlled study of 1762 LSG from 2006-2014 was performed. All radiographically confirmed leaks were included. Controls were patients who underwent LSG without leak, selected using a 10:1 (control:study) case-match. Data included patient characteristics, intraoperative factors, and esophagram results. Clinical indicators including SIRS criteria (presence of = 2: temperature<36 degreeC or >38 degreeC, heart rate>90 bpm, respiratory rate>20 breaths/min,WBC>12,000 or <4,000) and self-reported pain score were collected on postoperative day (POD) 2 and at the time of leak, if applicable. Statistics included univariate analyses and multivariate logistic regression. Results: Of the 1762 LSG, 20 (1.1 %) leaks were compared with 200 case-matched controls. Three patients developed leak during their index admission (mean = 1.3 days, range = [1,2]), while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days (median = 15, range = [4,63]) postoperatively. Leaks were similar to controls in baseline characteristics; however, the leak group had fewer black patients (5 % vs. 17 %, p = 0.022). There were no differences in intraoperative characteristics including staple reinforcement, bougie size, leak test, or operativetime between groups. Contrast extravasation on routine postoperative esophagram was seen in only two (10 %) of the twenty patients with enteric leaks; other esophagram findings (e.g. delay, dilatation) did not differ between leaks and controls. Patients with both early and late leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent factors associated with leak included fever (p<0.0001), SIRS criteria (p = 0.0034), and pain score = 9 (p = 0.010). Conclusions: Contrast extravasation on routine postoperative esophagram may detect early leaks after LSG, but the vast majority of leaks have normal results and present days to weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study, and may be used as criteria to selectively obtain postoperative esophagrams after LSG

Aims: Local ablative therapies, such as radiofrequency ablation (RFA) and microwave ablation (MWA), are commonly used to treat patients with unrespectable or recurrent hepatocellular carcinoma (HCC). These therapies are generally safe and well tolerated, yet complications related to mechanical or thermal damage may result. This case highlights a very rare complication after local ablative therapy for HCC, namely diaphragmatic perforation, and demonstrates a step-by-step laparoscopic repair. Methods: This is the case of an 81-year-old female with segment 4B hepatocellular carcinoma diagnosed in 2008, treated with laparoscopic radiofrequency ablation. The disease recurred in 2012 and subsequent microwave ablation and trans-arterial chemoembolization were performed. One year later, the patient developed severe right upper quadrant abdominal pain. CT scan showed incarcerated colon and cecum herniating through the right diaphragm with associated colonic obstruction. The patient was taken to the OR for laparoscopic repair of the diaphragm and possible bowel resection. With the patient in the right lateral decubitus position, the terminal ileum, cecum, and right colon were reduced and the diaphragm repaired with 0-prolene sutures in a horizontal mattress fashion. A 34 French chest tube was placed. Upon further inspection, the right colon appeared gangrenous. The patient was then repositioned into the supine position and a laparoscopic right hemicolectomy was performed. Results: The patient was extubated on postoperative day 1. Recovery was complicated by a subdiaphragmatic abscess, which responded to percutaneous drainage and antibiotics. The patient was subsequently discharged to a subacute rehab facility. Conclusion: With only a few cases cited in the literature, diaphragmatic perforation is an uncommon complication of local ablative therapies for HCC. The mechanism of injury is presumably thermal injury to the diaphragm. In cases of acute right upper quadrant abdominal pain after RFA or MWA, this rare but serious complication should remain in the differential

Marginal Ulcers (MU) are the most common cause of bleeding after RYGB. Surgical management is required if endoscopic treatment fails to control the bleeding. In this video, we present the case of a laparoscopic repair of an actively bleeding marginal ulcer after RYGB. The repair was performed via a jejunal enterotomy with meticulous ligation of bleeding vessels, and did not require revision of the gastrojejunal anastomosis