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Is endoscopic stenting for sleeve leaks always necessary? a comparison of management protocols [Meeting Abstract]

Horwtz, D; Saunders, J; Chau, E; Ude, A; Chui, P; Ren-Fielding, C; Fielding, G; Schwack, B; Kurian, M; Parikh, M
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
EMBASE:619777670
ISSN: 1878-7533
CID: 2886432

Weight loss outcomes among patients referred after primary bariatric procedure

Obeid, Nabeel R; Malick, Waqas; Baxter, Andrew; Molina, Bianca; Schwack, Bradley F; Kurian, Marina S; Ren-Fielding, Christine J; Fielding, George A
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
PMID: 26307420
ISSN: 1879-1883
CID: 1742152

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study

Sethi, Monica; Magrath, Melissa; Somoza, Eduardo; Parikh, Manish; Saunders, John; Ude-Welcome, Aku; Schwack, Bradley; Kurian, Marina; Fielding, George; Ren-Fielding, Christine
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.
PMID: 26416376
ISSN: 1432-2218
CID: 1789772

Previous weight loss as a predictor of weight loss outcomes after laparoscopic adjustable gastric banding

Sethi, Monica; Beitner, Melissa; Magrath, Melissa; Schwack, Bradley; Kurian, Marina; Fielding, George; Ren-Fielding, Christine
INTRODUCTION: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary LAGB patients. METHODS: A retrospective cohort study was designed from a prospectively collected database at a single institution. Inclusion criteria consisted of age >/=18 years, initial body mass index (BMI) >/=35 kg/m2, intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery were excluded. Outcomes included mean % excess weight loss (EWL), percent that achieved weight loss success (%EWL >/= 40), and percent with suboptimal weight loss (%EWL < 20) at 2 years post-LAGB. RESULTS: In the study, 462 primary LAGB patients were included. Mean previous weight loss was 29.7 lb (SD 27.6, range 0-175). These patients were divided into four previous weight loss groups (0, 1-20, 21-50, >50 lb) for analysis. In adjusted multivariate analyses, patients with >50 lb of maximum previous weight loss had a significantly higher mean %EWL, (p < 0.0001) and %BMIL (p < 0.0001), were more likely to reach weight loss success (>/=40 % EWL, p = 0.047), and were less likely to experience suboptimal weight loss (<20 % EWL, p = 0.027) at 2 years postoperatively. CONCLUSION: Previous weight loss appears to be a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.
PMID: 26205561
ISSN: 1432-2218
CID: 1684082

The utility of esophagram and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy [Meeting Abstract]

Sethi, M; Magrath, M; Somoza, E; Parikh, M S; Saunders, J K; Ude-Welcome, A O; Schwack, B; Kurian, M; Fielding, G; Ren-Fielding, C
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
EMBASE:72209643
ISSN: 0930-2794
CID: 2049642

The safety of laparoscopic sleeve gastrectomy among non-insulin dependent diabetics [Meeting Abstract]

Sethi, M; Schwack, B; Kurian, M; Fielding, G; Ren-Fielding, C
Aims: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed primary bariatric procedure. Although bariatric surgery is becoming increasingly recognized as an effective 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 the subset of diabetic patients who do not require insulin (NIDDM). Methods: Patients 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, comorbidity, hospital 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. Chi-square, Fisher's exact, and two-sample t tests were used to evaluate differences between groups. Results: Of 6062 LSG performed in 2012, 4726 (83.4 %) were non-diabetic and 941 (16.6 %) were NIDDM. NIDDM were more likely to be male (28.9 % vs. 19.3 %, p<0.001), older (47.6 years vs. 42.5 years, p<0.001), and had a higher BMI (46.4 kg/m2 vs. 45.7 kg/m2, p = 0.027) when compared to non-diabetics. In addition to diabetes, NIDDM had a higher rate of COPD (2.8 % vs. 0.6 %, p<0.001). The NIDDM group had a slightly longer mean operative time, as well (101.1 vs. 96.9 minutes, p = 0.014). The overall 30-day complication rate did not differ between groups (6.5 % NIDDM vs. 5.6 % non-diabetic, p = 0.305). In sub-analyses of specific complications, NIDDM had a slightly higher rate of blood transfusions (1.8 % vs. 1.0 %, p = 0.037). Other postoperative complications, including wound infection, intraabdominal infection, sepsis, renal injury, urinary tract infection, postoperative myocardial infarction, cardiac arrest, deep vein thrombosis, reoperation, and readmission did not differ between groups. Conclusion: Laparoscopic sleeve gastrectomy is a safe procedure for non-insulin dependent diabetics with regards to early post-operative complications
EMBASE:72209784
ISSN: 0930-2794
CID: 2049632

Laparoscopic sleeve gastrectomy for failed laparoscopic gastric banding [Meeting Abstract]

Sethi, M; Schwack, B; Kurian, M; Ren-Fielding, C; Fielding, G
Aims: Although laparoscopic bariatric surgery is accepted as the most effective treatment for morbid obesity, some patients fail to lose weight, develop postoperative weight regain, or develop other complications. Revisional bariatric surgery can correct such complications. Our video highlights sleeve gastrectomy as a revisional procedure for failed laparoscopic adjustable gastric banding. Methods: This patient is a 36-year-old male with a BMI of 42 kg/m2. Following a Lap- Band procedure three years ago, the patient failed to lose weight because dysphagia and reflux prevented him from tolerating Lap-Band adjustments. An upper GI series confirmed that the band was in good position. The decision was made to remove the Lap-Band and convert him to a sleeve gastrectomy. The operation began with lysis of adhesions and release of the gastrogastric plication, allowing removal of the band. The underlying pseudocapsule was excised in order to minimize the disparity in tissue thickness during stapling, as well as to relieve any constriction on the gastric tissue. The greater curvature of the stomach was mobilized proximally to the angle of His and distally to a point 2-3 cm proximal to the pylorus. A 40-French bougie was placed down to the duodenum and a longitudinal sleeve gastrectomy was performed with multiple firings of a linear stapler covered with bioabsorbable staple-line reinforcement material. The upper portion of the staple line was oversewn with omentum and the incisura was sutured down to the transverse mesocolon to prevent rotation. Operative time was 51 minutes and blood loss was 20 cc. Results: An esophagram on the first postoperative day demonstrated a normal sleeve gastrectomy without leak or obstruction. The patient was able to tolerate thin liquids, and was discharged home on the second postoperative day. Two months after surgery, the patient is doing well with no dysphagia or reflux and a current BMI of 38 kg/m2. Conclusions: Laparoscopic sleeve gastrectomy is a safe and feasible solution for laparoscopic adjustable gastric band intolerance and failure of weight loss. The procedure can be safely performed in a single-stage with concurrent removal of the gastric band
EMBASE:72210206
ISSN: 0930-2794
CID: 2049622

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy

Sethi, Monica; Zagzag, Jonathan; Patel, Karan; Magrath, Melissa; Somoza, Eduardo; Parikh, Manish S; Saunders, John K; Ude-Welcome, Aku; Schwack, Bradley F; Kurian, Marina S; Fielding, George A; Ren-Fielding, Christine J
BACKGROUND: Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. METHODS: A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 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, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. RESULTS: A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8 %), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7 %) cases, while 221 (14.3 %) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1 %) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1 %, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. CONCLUSION: Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.
PMID: 26092015
ISSN: 1432-2218
CID: 1631142

Laparoscopic reversal of nissen fundoplication with conversion to 180-degree anterior fundoplication for obstructive dysphagia [Meeting Abstract]

Sethi, M; Schwack, B; Kurian, M; Ren-Fielding, C; Fielding, G
Aims: Laparoscopic Nissen fundoplication is the most commonly performed surgical procedure for severe gastroesophageal reflux. Recent studies, however, have shown the 180-degree anterior fundoplication to be equivalent in treating reflux and superior in treating dysphagia and gas-related symptoms. This video highlights the safe and effective laparoscopic revision of a Nissen to an anterior fundoplication for symptoms of obstructive dysphagia. Methods: A 56 y.o. male with refractory gastroesophageal reflux and a large hiatal hernia underwent an uncomplicated Nissen fundoplication with vagal preservation. After the operation, he developed symptoms of obstructive dysphagia, hiccups, and trapped air. Upper GI series demonstrated smooth narrowing of the gastroesophageal junction with delayed esophageal emptying and stasis. Endoscopic balloon dilation and medical therapy were unsuccessful and the symptoms persisted for over a year. The decision was made for reoperation to loosen the wrap. Intraoperatively, the Nissen fundoplication appeared to be in good position. The wrap was taken down and a portion of the fundus appeared damaged from the dissection and dense adhesions. The damaged fundus was resected with an Endo GIA linear stapler. An intraoperative methylene blue leak test did not identify any leaks. A 180-degree anterior fundoplication was performed to ensure suturing to healthy tissues. Operative time was 96 minutes and blood loss was 25cc. Results: The patient was discharged to home the same day and has had an uneventful recovery. At the 4-month follow-up, an upper GI series demonstrated normal appearance of the fundoplication, as well as normal esophageal emptying without delay or obstruction. The patient's dysphagia has improved and he has no reflux symptoms, but still has intermittent hiccups. Conclusion: In cases of severe dysphagia after Nissen fundoplication, laparoscopic conversion to a partial anterior fundoplication is a safe and feasible option. Complete takedown of the posterior wrap, recognition of normal anatomy, and avoidance of suturing to damaged tissues are essential components of this procedure
EMBASE:72210301
ISSN: 0930-2794
CID: 2049592

Laparoscopic subtotal gastrectomy and roux-en-y esophagojejunostomy for gastrogastric fistula following gastric bypass [Meeting Abstract]

Sethi, M; Lee, S; Schwack, B; Kurian, M; Ren-Fielding, C; Fielding, G
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
EMBASE:72210295
ISSN: 0930-2794
CID: 2049602