Faculty Bibliography

Aims: Gatstro-gastric fistula (GGF), a complication of roux-en-y gastric bypass (RYGB), has an occurrence rate of 1-2% and can result in weight regain, relapse of comorbidities, and marginal ulceration. Surgical management varies-revision of the bypass with concurrent remnant gastrectomy is often avoided for fear of complexity, while division of the fistula, remnant gastrectomy, and endoscopic repairs can result in recurrence of the GGF or marginal ulceration. Institutional data on GGF after RYGB and the step-by-step revision to an esophagojejunostomy are herein presented. Methods: This is a retrospective review of prospectively collected data at a single institution and video presentation. Results: Between 2005 and 2014, 13 patients presented with GGF after RYGB. The mean time to presentation was 4.4 years [range: 7 mos-16.4 years]. Surgical treatments included resection of GGF, remnant gastrectomy, and subtotal gastrectomy with either revision of gastrojejunostomy or esophagojejunostomy. Mean OR time was 191 minutes. Four patients required an additional reoperation for recurrent marginal ulcer (2), persistent GGF (1), and enterocutaneous fistula (1). Patients who underwent full resection of the gastric remnant and conversion to esophagojejunostomy did not develop postoperative complications. Video Presentation: A 47-year-old male s/p laparoscopic RYGB one year prior presented with 1 day of abdominal pain and was diagnosed with a GGF on CT scan. His weight loss was adequate and his BMI was 28.8. Marginal ulceration was presumed to be the source of his acute pain and the patient was taken to the OR for revisional surgery. Intraoperatively, the roux-limb and remnant stomach were divided. The GE junction was marked and divided proximally to the GGF and an endoscopic stapler created an end-to-side esophagojejunal anastomosis. The gastric remnant, gastrojejunostomy, and GGF were removed through the umbilical incision. Incidentally found internal and hiatal hernias were also repaired. Total operative time was 162 minutes. On 6 months follow-up the patient has no complications. Conclusion: Surgical treatment of GGF after RYGB should include revision to esophagojejunostomy with complete excision of the gastric remnant. In experienced hands, this operation is safe and effective and has a lower likelihood of recurrent GGF and marginal ulceration compared to other procedures

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

BACKGROUND: Although metabolic surgery was originally performed to treat hypercholesterolemia, the effects of contemporary bariatric surgery on serum lipids have not been systematically characterized. METHODS AND RESULTS: MEDLINE, EMBASE and Cochrane databases were searched for studies with >/=20 obese adults undergoing bariatric surgery [Roux-en-Y Gastric Bypass (RYGBP), Adjustable Gastric Banding, Bilio-Pancreatic Diversion (BPD), or Sleeve Gastrectomy]. The primary outcome was change in lipids from baseline to one-year after surgery. The search yielded 178 studies with 25,189 subjects (pre-operative BMI 45.5+/-4.8kg/m2) and 47,779 patient-years of follow-up. In patients undergoing any bariatric surgery, compared to baseline, there were significant reductions in total cholesterol (TC; -28.5mg/dL), low density lipoprotein cholesterol (LDL-C; -22.0mg/dL), triglycerides (-61.6mg/dL) and a significant increase in high density lipoprotein cholesterol (6.9mg/dL) at one year (P<0.00001 for all). The magnitude of this change was significantly greater than that seen in non-surgical control patients (eg LDL-C; -22.0mg/dL vs -4.3mg/dL). When assessed separately, the magnitude of changes varied greatly by surgical type (Pinteraction<0.00001; eg LDL-C: BPD -42.5mg/dL, RYGBP -24.7mg/dL, Adjustable Gastric Banding -8.8mg/dL, Sleeve Gastrectomy -7.9mg/dL). In the cases of Adjustable Gastric Banding (TC and LDL-C) and Sleeve Gastrectomy (LDL-C), the response at one year following surgery was not significantly different from non-surgical control patients. CONCLUSIONS: Contemporary bariatric surgical techniques produce significant improvements in serum lipids, but changes vary widely, likely due to anatomic alterations unique to each procedure. These differences may be relevant in deciding the most appropriate technique for a given patient.

BACKGROUND: Adjustable gastric bands have undergone significant design changes since their introduction. Band diameter, balloon volume, and shape have been modified to create high balloon fill volumes but lower and more evenly distributed pressure on the upper stomach. There have been few comparative studies on complication rates with different band types. OBJECTIVES: To compare complication rates among different types of adjustable gastric bands at a single institution. SETTING: University-affiliated hospital, United States. METHODS: We performed a retrospective cohort study of adult patients with a body mass index>/=35.0 kg/m(2) who underwent laparoscopic adjustable gastric banding from January 1, 2001 to December 31, 2007 and were followed for at least 5 years. Primary outcomes of the analysis were complications requiring operative management at our institution within the first 5 years after initial band placement. Reoperative procedures included diagnostic laparoscopy, hiatal hernia repair, band repositioning, replacing the band, removing the band, and converting to another bariatric procedure. RESULTS: For this study, 2711 patients met the inclusion criteria-1827 (67.4%) women and 884 (32.6%) men. Bands initially implanted included first-generation bands, LAP-BAND 9.75 cm (24.0%), 10 cm (33.9%) and Vanguard (24.8%) and second-generation bands, AP standard (9.5%) and AP large (7.9%). Four hundred and eighty-five patients experienced complications requiring reoperation. The 5-year follow-up rate was 63.3%. In the first 5 postoperative years there were significantly fewer complications with second-generation bands (10.0% versus 19.5%, P<.0001). Smaller, older bands had the highest complication rates (LAP-BAND 9.75 cm, 28.2%) and complication rates decreased with each successive model. Rates of band removal were not different between first- and second-generation bands. The rate of multiple complications was low at 1.5%. CONCLUSION: First-generation bands are associated with higher complication rates. Our study found that complication rates decreased with each successive model. We can expect that future design modifications will continue improve the performance with the adjustable gastric band. (Surg Obes Relat Dis 2015;0:000-00.) (c) 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.

BACKGROUND: Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG). METHODS: We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission. RESULTS: Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) >/=3 days (OR 2.54, CI = [1.19, 5.40]), intraoperative drain placement (OR 3.11, CI = [1.58, 6.13]), postoperative complications (OR 8.21, CI = [2.33, 28.97]), and pain at discharge (OR 8.49, CI = [2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR 72.4, CI = [15.8, 330.5]). CONCLUSIONS: The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

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.

BACKGROUND: Short- and mid-term data on Roux-en-Y gastric bypass (RYGB) indicate sustained weight loss and improvement in co-morbidities. Few long-term studies exist, some of which are outdated, based on open procedures or different techniques. OBJECTIVES: To investigate long-term weight loss, co-morbidity remission, nutritional status, and complication rates among patients undergoing RYGB. SETTING: An academic, university hospital in the United States. METHODS: Between October 2000 and January 2004, patients who underwent RYGB>/=10 years before study onset were eligible for chart review, office visits, and telephone interviews. Revisional surgery was an endpoint, ceasing eligibility for study follow-up. Outcomes included weight loss measures and rates of co-morbidity remission, complications, and nutritional deficiencies. RESULTS: RYGB was performed in 328 patients with a mean preoperative body mass index of 47.5 kg/m2. Of 294 eligible patients, 134 (46%) were contacted for follow-up at>/=10 years (10+Year follow-up). Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year. Higher %EWL was achieved by non-super-obese versus super-obese (61.3% versus 52.9%, P = .034). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. At 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. All-cause mortality was 2.7%. Nutritional deficiencies were seen in 87% of patients. CONCLUSIONS: Weight loss after RYGB appears to be significant and sustainable, especially in the non-super-obese. Co-morbidities are improved, with a substantial number in remission a decade later. Nutritional deficiencies are almost universal.

BACKGROUND: Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere. METHODS: We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management. RESULTS: Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P