Faculty Bibliography

Introduction: Several studies have shown that obesity is more common among patients with psoriasis and psoriatic arthritis, and this correlation may be related to the systemic inflammation associated with obesity. Although bariatric surgery has been shown to improve several obesity-related comorbidities, the effects of surgical weight loss on psoriasis and psoriatic arthritis have not been adequately studied. Our objective was to investigate the effects of weight loss from bariatric surgery on psoriasis and psoriatic arthritis. Methods: A retrospective database of 9,073 bariatric surgeries performed at a single center between 2002 and 2013 was queried. Patients with a diagnosis of psoriasis prior to bariatric surgery were identified. Preoperative demographic, anthropometric, and comorbidity data were collected. Patients were contacted about their history of psoriasis, changes in symptoms after surgery, diagnosis of psoriatic arthritis, and treatment modalities for psoriasis and psoriatic arthritis pre- and postoperatively. The primary outcome was the percentage of patients who reported improvement in psoriasis after surgery. Secondary analyses were performed to define factors associated with improvement in psoriasis. Results: We identified 128 patients with a preoperative diagnosis of psoriasis. Seventy-four (58%) patients completed the study. Baseline patient characteristics are listed in Table 1. The mean time from surgery was 6.2 years, with a mean excess weight loss (EWL) of 46.5%. At the time of contact, forty-one (55%) patients reported improvement in their psoriasis, 24.3% reported improvement with subsequent relapse, 6.8% had no change, and 12.6% reported that their psoriasis progressively worsened. Sixteen (22%) patients also had a preoperative diagnosis of psoriatic arthritis; 62.5% reported improvement in their psoriatic arthritis, whereas 19% had no change and 19% worsened. In secondary analyses, lower preoperative BMI (43.7kg/m² vs. 48.4 kg/m², p=0.004) was found to be independently associated with postoperative improvement in psoriasis. Patients with severe psoriasis at the time of surgery and significant postoperative improvement, excluding those whose improvement may have been due to escalation in medication class, demonstrated greater weight loss (101.4 lb vs. 66.0 lb, p=0.025) and EWL (63.7% vs. 44.7% EWL, p=0.028). Similarly, improvement in psoriatic arthritis was associated with greater EWL, but this did not reach statistical significance (51.4 vs. 48.3, p=0.815). Conclusion: Although the natural history of psoriasis and psoriatic arthritis is typically chronic, a majority of patients experience improvement after bariatric surgery. Based on our results, there is an association between excess weight loss and symptomatic improvement in severe cases of psoriasis. Factors such as lower preoperative BMI may be used to identify those patients with a greater likelihood of remission. Additionally, ours is the first study to show an improvement in psoriatic arthritis after bariatric surgery and a possible association between surgical EWL and improvement in psoriatic arthritis. Larger prospective studies are needed to further define the true effect of surgical weight loss on psoriasis and psoriatic arthritis

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: 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: 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: 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: Bariatric surgery has proven to be the most effective treatment for sustained, longterm weight loss. However, surgeons are encountering some patients with weight regain and 'weight-loss failure.' Revisional bariatric surgery is becoming more common. Our video highlights gastric banding of the gastric pouch as a feasible option for revisional surgery. Methods: The case is a 55 year-old man with morbid obesity who underwent Roux-en-Y gastric bypass 10 years prior to presentation. He suffered from significant weight regain and was again classified as morbidly obese. Workup included an upper GI series, which demonstrated a dilated gastric pouch. The patient elected to undergo gastric banding of the gastric pouch in order to provide restriction and facilitate weight loss. Operative details are illustrated. Results: The patient was discharged to home the same day and has had an uneventful recovery. Most recently, at the 4-month postoperative visit, the patient has lost 30 pounds. Conclusions: Revisional bariatric surgery is becoming more prevalent, especially for weight regain. Depending on the patient's symptoms, surgical anatomy, and preoperative workup, the 'band over bypass' technique is a feasible option for revisional surgery and is effective in managing weight regain after gastric bypass

Aims: We present an interesting case of laparoscopic repair of a giant paraesophageal hernia with simultaneous bariatric surgery. The technical aspects of this challenging operation are reviewed. The video also highlights the resulting major morbidity that can occur. Methods: A 66 year-old woman was diagnosed with a type IV paraesophageal hernia including stomach, colon, and pancreas in the left chest. She was scheduled for laparoscopic repair of the hernia defect, expressing interest in concurrent bariatric surgery. Intraoperatively, the gastroesophageal junction could not be pulled into the abdomen without significant tension. We extended the Collis gastroplasty to perform a concomitant sleeve gastrectomy. The details of the operative approach are illustrated. Results: On postoperative day 2, an esophagram revealed normal passage of contrast without leak or obstruction. However, on postoperative day 6, she became febrile, with persistent tachycardia and leukocytosis. A CT scan showed a large mediastinal fluid collection consistent with a leak. The patient was taken emergently to the OR for EGD, thoracotomy, decortication, and repair of distal esophageal perforation with muscle interposition graft. On postoperative day 7 after esophageal repair, an esophagram revealed contrast extravasation from the distal esophagus. The patient underwent a repeat thoracotomy, debridement, and esophageal resection with exclusion due to necrosis, placement of pharyngostomy tube, as well as laparotomy, gastrostomy and jejunostomy tube placement. The patient was eventually discharged to a nursing facility after a prolonged hospitalization with pulmonary and infectious complications. She required multiple readmissions for tube maintenance and infectious complications. Several months later, after nutritional optimization, she is recovering from a right thoracotomy and Roux-en-Y esophagojejunostomy. Conclusions: Large paraesophageal hernias can cause debilitating symptoms, and laparoscopic repair is often complex in nature. In morbidly obese patients, extending the Collis gastroplasty into a vertical sleeve gastrectomy can help to address the morbid obesity. However, patients must be counseled on the many serious risks and complications associated with this procedure

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