Faculty Bibliography

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: 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

Purpose: Obesity is a modifiable risk factor of knee osteoarthritis (KOA). While diet, exercise and other conservative treatments can have limited and often transient beneficial effects, an alternative strategy would target weight loss via surgery to delay or avoid joint replacement. Some retrospective data, including a study from our group, have in fact shown sustained improvement in KOA pain after bariatric surgery. We initiated a prospective study to evaluate painful KOA in the obese population, and track whether weight loss after bariatric surgery affects KOA-related pain and physical function. Methods: We screened consecutive patients prior to laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy, or gastric bypass (RYGB), at NYU Langone Medical Center and Bellevue Hospital Center. Patients age >21 with knee pain for >1 month and a visual analog scale pain score >30mm were enrolled, excluding those with lupus, rheumatoid arthritis, psoriatic arthritis, or psoriasis. Baseline pre-op assessments included x-rays for OA severity by Kellgren-Lawrence (KL) grade, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) with a Likert scale calculated from the KOOS. Patients were consented for optional tissue collection (blood, urine and intra-operative adipose samples) for future biomarker analysis. They are (still) completing the questionnaires and being measured for BMI and % excess weight loss (%EWL) at 1,3,6 and 12 month post-op intervals. Results: In total, we screened 537 patients planning to have bariatric surgery, found that 309 (58%) of them reported knee pain - and enrolled 176who met criteria and consented for the study. Our cohort is 89.7% female, with a mean BMI of 43.6 kg/m2+/-7 (31.6-60.6), a mean age of 42.4 +/-11 (18-73), and radiographic severity as follows: KL0=43 (25%), KL1=34 (19%), KL2=38 (22%), KL3=34 (19%), KL4=27 (15%). The mean pre-op KOOS scores were 45.4 for pain and 46.0 for ADL (0=worst, 100=best), the mean pre-op WOMAC pain score (Likert scale) was 11 (0=best, 20=worst), and the mean overall WOMAC index was 52 (0=best, 96=worst). Before surgery, a higher KL correlated with symptoms; mean KOOS pain was 53.2, 48.1 and 36.7 for KL0, KL1-2, and KL3-4 (p=0.00002 for KL0 vs KL3-4, and p=0.0005 for KL1-2 vs KL3-4), with similar trends across other KOOS and WOMAC scores. Higher BMI also trended with worse pre-op knee symptoms, as the tertiles with the lowest and highest BMIs (31-39 and 46-61) had mean KOOS pain scores of 46.8 and 43.7 (p=0.37). While 23 ultimately decided against weight loss surgery, we are collecting post-operative data on the 153 patients (40 RYGB=26%, 93 sleeve=61%, 20 LAGB=13%). Improvement in average KOOS and WOMAC scores over baseline has been observed at all intervals (67, 71, 65, and 42 responses at 1,3,6,12 month visits), with more improvement farther after surgery. At 6 months post-op, mean KOOS scores available thus far improved 29 points for pain, with mean WOMAC pain and index improving by 6 and 22 points. The %EWL correlated with knee symptoms at each interval and for all followups combined, as the smallest and largest %EWL quartiles (4-29%, 54-92%) showed mean improvements of 18 and 31 points (p=0.03) in KOOS pain - mirrored across KOOS and WOMAC scores. RYGB and sleeve yielded higher %EWL than LAGB (44%, 43% vs. 37%) across all intervals, and greater improvement in mean KOOS and WOMAC scores (e.g. mean KOOS pain increased by 28, 29 and 8). Neither presence nor severity of KOA severity affected knee pain improvement from weight loss. Conclusions: These data suggest that bariatric surgery improves patients' KOA pain proportional to percent excess weight loss, with durability over time. RYGB and sleeve gastrectomy have more impact on knee symptoms than LAGB. While patients with worse KL grades report more baseline pain and disability, as expected, x-ray severity did not impact the response to surgical weight loss

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: 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

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)

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