Faculty Bibliography

Perforated duodenal ulcer following RYGB is an unusual clinical situation that may be a diagnostic challenge. Only 23 cases have previously been reported. We present five cases. The hallmark of visceral perforation, namely pneumoperitoneum, was not seen in three of the four cases that underwent cross sectional imaging. This is perhaps due to the altered anatomy of the RYGB that excludes air from the duodenum. Our cases had more free fluid than expected. The bariatric surgeon should not wait for free intraperitoneal air to suspect duodenal perforation after RYGB.

Introduction: We aimed to create a morbidity prediction score for patients undergoing RYGB using MBSA-QIP data. Methods and Procedures: We retrospectively analyzed all RYGB cases in MBSA-QIP during 2015, and identified factors associated with 30-day complications using chi-squared analysis. Multiple logistic regression identified pre-operative factors independently associated with 30-day complication to develop a prediction score, verified using a Cochran Armitage trend test. Results: For 42,849 procedures, there were 3034 (7.1%) with any 30-day complication. Preoperative patient characteristics independently associated with increased risk of morbidity are shown in Table 1. A scoring algorithm was formulated by assigning points based on strength of the odds ratio (Table 1), with the final score a summation of points accrued. The rate of any 30-day complication was evaluated across the range of scores (Table 2). Higher scores were associated with a higher rate of morbidity (p<0.0001 for each). [Figure Presented] Conclusion: We created and verified a morbidity prediction score for patients undergoing RYGB based on MBSA-QIP data

Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a common and effective form of bariatric weight loss surgery. However, a subset of patients will fail to achieve the expected total body weight loss (TBWL) greater than 20% after 12 months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. Although alternative procedural interventions exist for operative revision after suboptimal RYGB weight loss, laparoscopic adjustable gastric banding (LAGB) provides an option with short operative time, low morbidity, and effective results. We have previously demonstrated that short-term (12-month), and mid-term (24-month) weight loss is achievable with LAGB for failed RYGB. The objective of this study is to report the long term 5 year outcomes of LAGB after RYGB failure. Methods and Procedures: A retrospective review of prospectively collected data before and after RYGB when available, and before and after revision with LAGB was performed. The data included weight, height, body mass index, gender, race, age, operative time, length of stay, postoperative complications, and percentage of total body weight loss. Results: A total of 182 patients (81.3% female, 18.7% male) were included in this study. The mean age of patients undergoing LAGB after RYGB was 47+/-9.98 years old. The majority of patients (98.4%) underwent gastric band placement laparoscopically, with 2 patients requiring conversion to an open procedure, and 1 planned open approach. The mean preoperative weight was 319+/-64 lbs and BMI of 53+/-10 kg/m² before RYGB. After RYGB, patients experienced a mean %TBWL of 16+/-11%, had a weight of 264+/-50 lbs, and a BMI of 43+/-7 kg/m² before undergoing LAGB an average of 9 years after their first bariatric procedure. At the time of 5 year follow up after LAGB the patients had a %TBWL of 35+/-13%, weight of 201.9+/-46 lbs, and had a BMI of 33+/-7 kg/m². The mean operative time was 73+/-34 minutes and 85% of patients had a hospital length of stay less than 24 hours. Conclusion: The results of our study have shown that LABG had good long term data as a revi-sionary procedure for weight loss failure after RYGB. Patients experienced a satisfactory amount of total body weight loss with reduction in BMI and had a short operative time and length of stay

BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

Aim: The literature supports comparable safety profiles in regard to performing one vs. two stage revisional conversions of laparoscopic adjustable gastric bands to sleeve gastrectomies. In this discussion, we compare weight loss differences between one and two stage gastric band removal to sleeve gastrectomy procedures. The reasoning behind this discussion is the question: can an appropriately sized sleeve be created at the same time as gastric band removal (assuming scar tissue and tissue swelling), and can that sleeve permit adequate weight loss? Methods: This is a retrospective review of patients who underwent gastric band removal and subsequent sleeve gastrectomies between 2008 and 2016. We reviewed each patient's BMI at the time of the revisional sleeve gastrectomy and compared the BMI reduction (BMIR) and percentage total body weight loss (%BWL) after one year between patients undergoing a concurrent gastric band removal and sleeve gastrectomy vs. those undergoing a gastric band removal with an interval sleeve gastrectomy (3 or more months after band removal). Results: Between 2008 and 2016 there were 259 patients who underwent surgery converting a gastric band to a sleeve gastrectomy (191 one stage, 68 two stage). We compared the weight loss parameters for those following up at one year for both one stage and two stage conversions (104 one stage, 38 two stage). One stage conversions exhibited a 16.95% total body weight loss while two stage conversions exhibited a 17.95% total body weight loss (p=0.08). BMI reduction was also reviewed at one year showing 7.49 for one stage and 7.95 for two stage procedures (p=0.81). Conclusions: The safety of one vs. two stage laparoscopic adjustable gastric band conversion to sleeve gastrectomy has been supported in the literature. We demonstrate that there is no statistical difference in weight loss, after one year, between patients having their conversion at the same time (one stage) or in an interval manner (two stage). Therefore, there appears to be no weight loss benefit favoring a one vs. two stage procedure-thus leaving the choice up to surgeon's level of operative comfort and preference

AIMS: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric procedure. Although bariatric surgery is becoming increasingly recognized as a treatment option for diabetes, there remain concerns about the operative risks faced by diabetic patients. This study's objective was to determine the safety of bariatric surgery in diabetic patients, specifically the type 2 diabetic (T2DM) population. METHODS: Patients over 18 years of age with a body mass index (BMI) >/= 35 kg/m2 who underwent LSG in 2012 in the ACS-NSQIP database were identified. Emergency cases were excluded from analysis. Data included patient demographics, comorbidities, length of stay, and 30-day complications. The primary outcome was 30-day overall complication rate, and secondary outcomes included major complications and reoperation rates. RESULTS: There were 6399 LSG in the NSQIP database in 2012. Three hundred and twenty-two patients were excluded for BMI < 35, and 15 cases were deemed emergencies and excluded. Of the 6062 LSG who met the study criteria, 4726 (78 %) of patients were non-diabetic, 941 (15.5 %) had T2DM, and 395 (6.5 %) had T1DM. T2DM patients were more likely to be male (28.9 vs. 19.3 %, p < 0.001), were older (47.6 years vs. 42.5 years, p < 0.001), and had a higher BMI (46.4 vs. 45.7 kg/m2, p = 0.027) compared with non-diabetics. The overall 30-day complication rate did not differ between groups (6.5 % T2DM vs. 5.6 % non-diabetic, p = 0.292). After controlling for possible confounders, T2DM remained at no increased risk of 30-day complications (OR 1.16, 95 % CI 0.87-1.55, p = 0.301). In sub-analyses of specific complications, T2DM had a slightly higher rate of blood transfusions (1.8 vs. 1.0 %, p = 0.037). Other postoperative complications did not differ between groups. The 30-day complication rate for type 1 diabetics was greater than for T2DM (9.9 vs. 6.5 %, p = 0.031) and non-diabetics (9.9 vs. 5.6 %, p < 0.001). CONCLUSION: Laparoscopic sleeve gastrectomy is a safe procedure for type 2 diabetics with regard to early postoperative complications.

BACKGROUND: There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS). OBJECTIVES: To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS. SETTING: An academic, university hospital in the United States. METHODS: We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction. RESULTS: One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m2. Mean follow up was 8.2 years (range: 1-15 yr) with 72% 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. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m2 versus>/=50 kg/m2 and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery. CONCLUSION: This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.

Aims: Our institution implemented a Value-Based Medicine (VBM) clinical pathway to standardize the pre-, peri-, and post-operative management of longitudinal sleeve gastrectomy (LSG) patients. The goal of the program was to decrease patient length of stay (LOS) while maintaining the same clinical outcomes seen prior to initiation. Methods: The VBM pathway was instituted in September of 2014. A retrospective review was performed of all primary LSG cases from 2011-2015. Pre-VBM LSG patients were matched to post-VBM patients in a 1:1 ratio. Matching criteria were age within five years, body-mass index (BMI) within 5 kg/m, expected LOS within 0.5 days, same sex, and same status for prior abdominal surgery. Patients < 18 years of age, body mass index (BMI) < 35, and those with prior bariatric surgery were excluded from analysis. Primary outcomes were LOS, LOS > 2 days, operating room (OR) time, and cost per admission. Secondary outcomes included 30-day readmissions and reoperations. Results: There were 426 pre-VBM and 507 post-VBM patients. After matching for age, sex, BMI, expected LOS and previous abdominal surgery, there were 330 patients in each of the pre-VBM and post-VBM groups. There were no clinically significant demographic differences between the two groups. The post-VBM group had shorter mean OR time (75.1 vs 95.8 min, p<.0001), shorter LOS (1.50 vs 1.94 days, p<.0001), lower cost (median cost $792 less than pre-VBM group, p<.0001), and lower reoperation rate (0.0% vs 2.1%, p=.015). Readmission rate was lower in the post-VBM group, but did not reach statistical significance (2.7% vs 4.9%, p=.154). After controlling for hospital trends over time, LOS > 2 days (p=.008) and median cost (p=.019) remained significant. OR time (p=.058) and mean LOS (p=.338) still showed an improved trend, but could not be directly correlated to VBM implementation. Conclusions: Standardization of clinical care for LSG patients is feasible and effective. Patient length of stay and hospital cost were successfully decreased with no negative impact seen on 30-day post-operative outcomes

Introduction: Endoscopic stent placement after sleeve gastrectomy (LSG) leak is usually considered part of the treatment algorithm. We have experienced varying success with stents and have also seen patients who have difficulty tolerating the stent or who have experienced worsening leak with the stent. The purpose of this study is to review our experiences with these stents to contribute to the growing literature of the effectiveness in the management of sleeve leaks. Setting: Academic medical center. Methods: A retrospective review of all reported sleeve leaks between 2 high-volume bariatric surgery centers were reviewed. Data was collected on the presentation of these leaks as well as the entire post-operative course. Cases spanned from 2006 to 2016. Information was collected on clinical presentation, radiographic findings, endoscopic findings, stent placement, stent complications, re-intervention rate, and re-operation rate. Stent complications were defined as any persistent leak, PO intolerance, nausea/vomiting, radiographic evidence of migration, or abdominal pain that required either replacement/repositioning or removal of the stent. Results: 32 sleeve leaks were identified across our institutions. Two cases were excluded for lack of post-operative course data. 18 (60%) of 30 were treated at some point with an endoscopic stenting procedure. Complications that could be attributed directly to the stent were identified in 14 of the 18 cases (78%).The average number of interventions in the stent group was 3.7 compared to 0.75 in the no stent group (p<0.005).The average number of total admitted days was significantly higher in the stent group with 25.5 days versus 12.58 (p = 0.006). Conclusion: Patients who undergo stenting for the management of leak following a sleeve gastrectomy appear to require more interventions and have higher length of stay. Further studies are needed in order to better identify those patients who may benefit from endoscopic interventions and those who should be managed alternatively