Faculty Bibliography

Background: Laparoscopic sleeve gastrectomy (LSG), a commonly performed procedure for morbid obesity, can lead to serious complications such as enteric leak and bleeding. Splenic abscess is a rare complication of laparoscopic sleeve gastrectomy (LSG), with just one reported case in the Unites States. We herein present a case of splenic abscess after LSG. Methods: The patient is a 24y male with BMI 61kg/m² who underwent an uncomplicated LSG. Two months postoperatively, he presented with abdominal pain and computed tomography (CT) scan demonstrated splenic laceration, possible infarct. After seventy-two hours, the patient developed fever, tachycardia and leukocytosis. Empiric broad-spectrum antibiotics were initiated for a presumed superinfection of the splenic infarct. Repeat CT scan of the abdomen demonstrated a unilocular 15x16x10cm heterogeneous subcapsular splenic collection. A splenic artery angiogram confirmed that there was no active hemorrhage. A percutaneous drainage catheter drained the collection, after which the patient showed rapid clinical improvement. Results: The patient was discharged on antibiotics and the drainage catheter was removed two weeks later. At three-month follow-up, there is no evidence of infection. Conclusions: Splenic abscess may progress from splenic infarction after LSG. Presentation is nonspecific, may be easily confused with enteric leak, and can be delayed. Systemic illness can rapidly progress. CT imaging is the preferred diagnostic modality, but angiography may be necessary to exclude active bleeding. In patients with a unilocular abscess, early intervention with percutaneous drainage and IV antibiotics may prevent splenectomy

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

Introduction: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The primary 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 laparoscopic adjustable gastric banding patients. Methods: A retrospective cohort study was designed from a prospectively-collected database at a single institution. There were 999 patients who underwent primary LAGB between June 2010 and December 2011 who were considered for this study. 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 and patients without a recorded maximum previous weight loss were excluded. Data obtained included preoperative demographics, BMI, comorbidities, maximum amount of previous weight loss, and number of previous weight loss attempts, as well as postoperative weight (lbs), BMI, and percent excess weight loss (%EWL), at 12, 18, and 24 months postoperatively. The primary outcomes were mean %EWL, percent that achieve weight loss success (%EWL > 40), and percent with suboptimal weight loss (%EWL<20) at 2 years post-LAGB. Statistical analysis was performed using SAS, with tests including chi-square, ANOVA, linear and logistic regression. Results: Of the 999 patients, 462 primary LAGB patients met criteria. Mean previous weight loss was 29.7 lbs (SD = 27.6, range = [0,175]). These patients were divided into four previous weight loss groups (0 lbs, 1-20 lbs, 21-50 lbs, > 50 lbs) for analysis. Baseline patient characteristics between the four groups demonstrated that patients with the greatest previous weight loss (> 50 lbs) were more likely to be male (p = 0.01) and had higher baseline weight/BMI (p<0.0001). There were no differences in comorbidity or operative time between the groups. In order to account for the baseline differences between the four previous weight loss groups, an adjusted model was used for analysis, controlling for age, gender, baseline BMI, and band type. In the adjusted model, those with > 50 lbs of previous weight loss had 8.8 % EWL, 6.7 % EWL, and 5.0 % EWL more than those with 0, 1-20, and 21-50 lbs of previous weight loss, respectively (p<0.0001) [Table 1]. Patients with > 50 lbs of previous weight loss were more likely to achieve weight loss success (> 40 % EWL) at 2 years post-LAGB (p = 0.047), and were less likely to have suboptimal weight loss (<20 % EWL) at 2 years post-LAGB (p = 0.027). Conclusion: Previous weight loss is 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. (Table Presented)

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)

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. It is linked to obesity and the metabolic syndrome (MS), predisposing to future cirrhosis. The objective of this study was to demonstrate the effects that weight loss achieved with laparoscopic adjustable gastric band (LAGB) has on the metabolic parameters and NAFLD scores of obese adolescents with evidence of fatty liver disease. METHODS: Adolescents undergoing LAGB were evaluated for NAFLD with evidence of fatty liver on preoperative sonogram, serum biochemistry, or both between 2005 and 2011. Primary endpoint was change in NAFLD scores after LAGB and secondary endpoint change in MS criteria. RESULTS: Fifty-six out of 155 adolescents had evidence of fatty liver disease at presentation. The group consisted of 17 (30%) male and 39 (70%) females, mean age 16.1 years (range 14-17.8 yr). Preoperative body mass index (BMI) was 48.8 kg/m2 (+/-7) dropping to 37.9 kg/m2 (+/-8.3) at 12 months and 36.8 kg/m2 (+/-8.2) at 24 months. Fifteen (27%) patients met the criteria for MS. When comparing 1-year postsurgery to presurgery, the NAFLD score decreased by an average of .68 (SD = 1.03, P<.01). The 2-year NAFLD score decreased by a mean of .38 (SD = .99, P = .01). The reoperation rate for band/port related complications was 10.7% at 2 years with no mortality. MS rates improved from 27% to 2% at 2 years (P< .01). CONCLUSIONS: LAGB is a safe and effective operation for obese adolescents with NAFLD. There was significant improvement in NAFLD scores and resolution of MS.