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

Intro: Laparoscopic adjustable gastric banding is well-known for its safety profile. However, band removal, especially for a device-related complication, may be more complex due to the scar tissue created by the band. The objective of this study is to review perioperative outcomes of patients requiring band removal for device-related complications. Methods: A retrospective review was conducted of all band removals over a 13 year period (2001-2014) for a device-related complication (e.g. slippage, erosion, gastric necrosis). Bands removed for weight loss failure or intolerance were excluded from this review. Perioperative complication, readmission and reoperation/re-intervention was defined according to the Metabolicand Bariatric Surgery Accreditation and Quality Improvement Program standards. Results: A total of 104 patients required band removal for a device-related complication. In the same time frame 7633 bands were implanted. The average age at band removal was 44 years old and the average BMI was 35.6. The most common reason was slip (42%) and erosion (28%). The 30-day complication rate from the removal was 26% (27/104) - most commonly pneumonia and perigastric abscess. The 30-day readmission rate and reoperation/ re-intervention rate were 15% and 10%, respectively. There was one mortality (1%) from septic shock secondary to erosion. There were no statistically significant differences in age (p = 0.452) or BMI (p = 0.523) between those who had a 30-daycomplication and those who did not. Conclusions: Band-related complications are rare. Band removal for device-related complication may be associated with significant morbidity

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

Introduction: Biliopancreatic diversion (BPD) with or without duodenal switch (BPD-DS) produces more weight loss and amelioration of comorbidity than any other bariatric procedure. Yet, there is minimal long-term data on BPD; some of the data that exists is based on open procedures or uncommon techniques (i.e. transient gastroplasty), and most of it derives from centers outside the U.S. that use the BPD as their operation of choice for all bariatric patients, making this data difficult to generalize. The aim of our study was to investigate the long-term weight loss, remission of comorbidities, complications, and quality of life after BPD and BPD-DS at a single U.S. center Methods: We conducted a retrospective review of a prospective database all patients who underwent BPD or BPD-DS between 1999 and 2011. Data were also obtained from office visits and patient interviews. Outcomes included weight loss measures at 2, 5 and 10-15 years postoperatively, rates of comorbidity remission, long-term complications, and nutritional deficiencies. Additionally, a comprehensive subjective review of postoperative morbidity, quality of life and dietary changes was conducted. Results: One hundred patients underwent BPD (34%) or BPD-DS (64%). Mean age was 42.3 years, with 16% males. Mean preoperative BMI was 50.2 kg/m² [range 34.4-65.3]. Mean follow up was 8.2 years [range 1-15y] with 72 percent of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years [Figure 1]. Higher %EWL was achieved at > 10 years for those with preoperative BMI <50 kg/m² vs. >50 kg/m² (73.6% vs. 63.2%, p=0.042). Additionally, BPD-DS was associated with 11% greater EWL across the study period, when compared to BPD (p=0.0007). Preoperatively, 24% of patients had hypertension (HTN), 8% had hyperlipidemia (HL), and 14% had diabetes (DM). At 10-15 years postoperatively, remission of comorbidities was 75% for HTN, 75% for HLD, and 50% for DM. Thirty-seven percent of patients developed long-term complications requiring surgery (cholelithiasis 7%, internal hernia 8%, incisional hernia 9%, hiatal hernia 2%, bowel obstruction 7%, severe malnutrition 4%, weight loss failure 8%) at an average of 4.4 years postoperatively. There were no 30-day mortalities; however, there was one mortality secondary to severe malnutrition. Table 1 lists the prevalence of specific postoperative nutritional deficiencies for the entire study population, and stratified by surgery type. Patients who underwent BPD had a greater incidence of iron- and vitamin-deficiency anemia, whereas those who underwent BPD-DS had greater incidence of thiamine deficiency. On a subjective review of postoperative morbidity, the most common complaints were malodorous stool (89%), diarrhea (81%), oily incontinence (70%), fatigue (59%), food intolerance (51%), and hair loss (47%). Overall, however, 94% of patients reported satisfaction with their choice of surgery. Conclusion: This clinical experience supports the long-term safety and efficacy of BPD and BPD-DS at a single U.S. center. Higher levels of excess weight loss are achieved by those patients with a lower preoperative BMI and BPD-DS. While nutritional deficiencies and postoperative complications can be frequent, patient satisfaction remains high. There continues to be a need to educate young surgeons on this procedure and its after-effects, as it has significant benefits as a stand-alone procedure and may increase in demand as a secondary procedure post-sleeve gastrectomy for weight regain. (Table Presented)

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: 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