Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. In the early postoperative stage, gastrointestinal (GI) bleeding is an infrequent but potentially serious complication that usually results from bleeding at the gastroje-junostomy staple-line. Observant management with transfusion for stable patients and surgical exploration for unstable patients is typically recommended for early GI bleeding. We hypothesized that use of endoclips, which do not cause thermal injury to the surrounding tissues (or anastomosis), may be preferable to thermal approaches which could cause tissue injury. We report 2 cases of early GI bleeding after RYGBP that were successfully managed with endoclip application to bleeding lesions. Emergent endoscopy was performed, and major stigmata such as active spurting vessel and adherent clot were noted at the gastrojejunostomy staple-lines. Endoscopic hemostasis using endoclips was readily applied to bleeding lesions at staple-lines. Primary hemostasis was achieved, and there was no recurrent bleeding or complication. We conclude that therapeutic endoscopy can be performed safely for early bleeding after RYGBP. In patients with early bleeding after RYGBP, use of endoclips is mechanistically preferable to other options.     

A case study from the advanced bariatric life support initiative: Pulmonary embolism after laparoscopic gastric bypass

Pulmonary embolism is the leading cause of death after bariatric surgery and represents one of the many potential life-threatening conditions after bariatric surgery. The Advanced Bariatric Life Support (ABLS) initiative was developed to teach practising bariatric surgeons, emergency physicians, and allied health professionals the need for accurate and timely diagnosis and management of life-threatening bariatric surgery complications. This case study was derived from the ABLS file and discusses the difficulty in differentiating between two major complications after gastric bypass – pulmonary embolism vs leak. Accurate diagnosis and expeditious treatment are of utmost importance to prevent death associated with these serious bariatric surgical complications.     

Linitis plastica of the bypassed stomach 7 years after Roux-en-Y gastric bypass: a case report

Laparoscopic Roux-en-Y gastric bypass (RYGB) is currently the preferred surgical procedure to treat morbid obesity. It has proven its effects on excess weight loss and its positive effect on comorbidities. One of the main issues, however, is the post-operative evaluation of the bypassed gastric remnant. In literature, cancer of the excluded stomach after RYGB is rare. We describe the case of a 52-year-old woman with gastric linitis plastica in the bypassed stomach after Roux-en-Y gastric bypass, diagnosed by means of laparoscopy and Single-Balloon enteroscopy, and it is clinical importance. Linitis plastica of the excluded stomach after RYGB is a very rare entity. This case report shows the importance of long-term post-operative follow-up, and the importance of single-balloon enteroscopy for visualization of the bypassed stomach remnant, when other investigations remain without results. This case report is only the second report of a linitis plastica in the bypassed stomach after Roux-en-Y gastric bypass.     

Laparoscopic Roux-en-Y gastric bypass and the role of the surgical resident

BACKGROUND: Open Roux-en-Y gastric bypass (RYGB) is the gold standard for obesity surgery in this country. The introduction of a totally laparoscopic technique in 1994 has increased the demand for obesity surgery and for this particular approach. Several studies show comparable results and complications between the open and laparoscopic procedure. However, the continued study of surgical technique, analysis of results, and, in particular, the education of the surgical resident in this approach must be accomplished. METHODS: A retrospective analysis was performed of 204 patients undergoing attempted laparoscopic RYGB, with surgical resident involvement, from March of 2000 to April of 2002. Surgical candidates had a body mass index (BMI) greater than 40 with a history of failed diets. All procedures were performed by a single board-certified general surgeon (P.F.R.) at a tertiary-care, teaching, community hospital with surgical residents assisting. Age, sex, ideal body weight, preoperative BMI and weight, surgical time, length of stay, complications, and resident level and role were recorded. Surgical technique was refined during the study period. RESULTS: A total of 204 patients underwent attempted laparoscopic RYGB with 4 (2%) being converted to open procedures and 1 mortality. Surgical time averaged 182 minutes. The average length of stay was 1.8 days. Four patients (2%) developed postoperative anastomotic leaks. Three patients (1.5%) developed internal hernias requiring reoperation. Four patients (2%) developed postoperative hemorrhage. One patient (0.5%) had a pulmonary embolism. Surgical residents were involved in all procedures and gradually expanded their role as skill increased. CONCLUSIONS: Laparoscopic RYGB can be performed safely in a community setting with surgical residents as either assistant or surgeon, further preparing them to perform this and other advanced laparoscopic procedures after completion of their training.     

Effect of roux-en-Y gastric bypass on satiety and food likes: The role of genetics

Among factors influencing the outcome of bariatric surgery may be genetics and familial risk. The purpose of this study was to assess the etiology of obesity and its impact on hunger, satiety, and food likes in obese patients undergoing Roux-en-Y gastric bypass (RYGB). This study was based on 76 patients undergoing RYGB procedures performed by a single surgeon. A previously described 100-point obesity risk index (ORI) was used to assess familial obesity risk. Hunger and satiety were assessed using a standardized Visual Analog Scale "Snickers" test, and food preferences for regular vs. low-fat potato chips were measured preoperatively and postoperatively. Patients were stratified preoperatively into high ORI (n = 34) and low ORI (n = 42) groups. Before operation, high-ORI patients preferred high-fat (regular) potato chips to low-fat (baked) potato chips, whereas the low-ORI patients liked both food types equivalently (P < 0.05). After operation (n = 43), both groups showed lower preferences for high-fat potato chips (P < 0.05 for high-ORI group). As anticipated, hunger was dramatically suppressed after RYGB. However, there was more satiety in the high-ORI group (P < 0.05, ANOVA). Most patients undergoing bariatric surgery had a strong familial or genetic component to their disease. RYGB in high-ORI patients was associated with a significant decline in preference of fatty food and a significantly prolonged drop in hunger ratings after a fast and after a standard 282 kcal meal. The success of bariatric surgery may be influenced by the etiology of obesity.     

Open Roux-en-Y gastric bypass for the morbidly obese in the era of laparoscopy

BACKGROUND: Roux-En-Y gastric bypass (RYGB) has been the preferred operative treatment for morbid obesity. Recently, laparoscopic RYGB has been described. We reviewed our data and believe that open RYGB is still the better option. METHODS: One hundred three consecutive cases were retrospectively reviewed for preoperative conditions, perioperative outcomes, and postoperative complications with weight/health changes. RESULTS: The mean follow-up was 5 months. The mean percent excess body weight loss was 33%. Comorbidities improved 50% of the time. The mean operative time was 117 minutes with blood loss averaging 208 cc. The mean intensive care unit stay was 1.3 days, with a total hospital stay of 4.4 days. There was an 8% major complication rate and a 1% mortality rate. CONCLUSIONS: The health improvement and complication rates are comparable to published series on laparoscopic RYGB. With the technical complexity of the laparoscopic technique, open RYGB should remain the current standard of care, in most centers.     

Evaluation of the excluded stomach by double-balloon endoscopy after laparoscopic Roux-en-Y gastric bypass

Background: Morbid obesity has become a serious health problem. We have been performing laparoscopic Roux-en-Y gastric bypass (LRYGBP) for morbid obesity since February 2002. Although LRYGBP ameliorates complications of morbid obesity, postoperative investigation of the excluded stomach is difficult. In patients with a family history of gastric cancer, resection of the bypassed stomach is sometimes added, but this requires longer operating time. There are two problems associated with LRYGBP: the high rate of gastric cancer in Japan, and how to investigate the excluded stomach. Methods: To resolve these problems, we introduced double-balloon intestinal endoscopy. We report double-balloon endoscopy (DBE) in 4 patients. Results: No problems with advancing the endoscope were encountered during observation. We used an overtube to insert the scope further in order to avoid forming redundant loops in the small intestine, and two balloons to grip the intestinal wall. Although performing DBE involves a learning curve, there were no major obstacles to passage of the scope into the esophagus, small gastric pouch, lifted jejunum, the jejunojejunal anastomosis, Y-loop, duodenum and excluded stomach. Conclusion: Use of the double-balloon technique makes it possible to observe the GI tract after laparoscopic LRYGBP irrespective of the length between the gastrojejunostomy and the jejunojejunostomy.     

Laparoscopic adjustable gastric banding versus laparoscopic gastric bypass for morbid obesity: A single-institution comparison study of early results

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are common surgical procedures for morbid obesity, but few studies have compared LRYGB and LAGB. All patients who underwent LRYGB and LAGB by a single surgeon at Legacy Health System were identified from a prospectively maintained database. Preoperatively, most patients were allowed to choose between LRYGB and LAGB. Age, sex, body mass index (BMI), complications, mortality, and weight loss were examined. From October 2000 to November 2003, 219 patients underwent LRYGB and 154 patients underwent LAGB. Mean preoperative BMI was 49.5 ± 6.6 and 50.9 ± 9.4 kg/m2, respectively (P = 0.10). Mean age was 42 ± 9 and 47 < 11 years (P < 0.001). The LAGB group had a higher proportion of male patients (21% versus 7%, P < 0.001). Patients undergoing LRYGB had longer operative times (134 versus 76 minutes, P < 0.001), more blood loss (43 versus 28 ml, P < 0.01), and longer hospital stays (2.6 versus 1.3 days, P < 0.001). Excess weight loss was 35% for LRYGB versus 19% for LAGB at 3-month follow-up (P < 0.001), 49% versus 25% at 6 months (P < 0.001), 64% versus 36% at 12 months (P < 0.001), 70% versus 45% at 24 months (P < 0.001), and 60% versus 57% at 36 months (P = 0.85). Major complications occurred in 7% and 6% (P < 0.58) and minor complications occurred in 18% and 20% (P = 0.65) of patients, respectively. Reoperation occurred in 21 patients (10%) after LRYGB and 31 (20%) patients after LAGB (P < 0.01). Of patients undergoing reoperation, eight (38%) LRYGB patients and one (3%) LAGB patient required open laparotomy. One death occurred in each group. Patients undergoing laparoscopic adjustable gastric banding have shorter operative times, less blood loss, and shorter hospital stays compared with laparoscopic gastric bypass patients. The incidence of major and minor complications is similar; however, morbidity after LRYGB is potentially greater and the reoperation rate is higher in the LAGB group. Early weight loss is greater with gastric bypass, but the difference appears to diminish over time. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). Supported in part by an educational grant from U.S. Surgical (Norwalk, CT).     

Introducing laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs medical facility

BACKGROUND: Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility. METHODS: A retrospective review was used. RESULTS: Between May of 2002 and April of 2004, 40 patients underwent laparoscopic RYGB. All patients met National Institutes of Health consensus statement guidelines for bariatric surgery. There were 30 (75%) male and 10 (25%) female patients, with an average age of 49.9 +/- 8.7 years and an average body mass index (BMI) of 48.1 +/- 8.5 kg/m(2). Preoperative comorbidities included diabetes mellitus (DM) in 59%, hypertension in 79%, and obstructive sleep apnea in 74.4%. The procedure was converted to an open procedure in 3 patients (7.5%). There were no mortalities. Immediate (within 30 days) complications developed in 9 (22.5%) patients, necessitating abdominal re-operation in 3 patients (7.5%). The median length of hospital stay was 3 days. Late complications (>30 days) developed in 8 (20%) patients. Percent excess weight loss at 3, 6, and 12 months was 44% (n = 34), 59% (n = 29), and 70.0% (n = 22), respectively. In 23 patients who were followed-up for more than 3 months, DM resolved in 79% and improved in 21% at a mean follow-up evaluation of 13 months. CONCLUSIONS: Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.     

Weight loss, quality of life and employment status after Roux-en-Y gastric bypass: 5-year analysis

BACKGROUND: Obesity can have a tremendous impact on the psychosocial, physical, and economic health of those afflicted by it. We hypothesized that if surgery results in significant weight loss and improves quality of life, those unemployed and disabled as a result of their morbid obesity might be more likely to become gainfully employed after Roux-en-Y gastric bypass (RYGBP). METHODS: We reviewed the medical charts of all patients who underwent RYGBP from April 1998 to December 1999. Demographics and employment status were obtained, along with preoperative weight, body mass index, Short Form 36 Health Survey and Beck Depression Inventory-II scores. For those employed, the recuperation time was also analyzed. Statistical analysis was performed using Student's t test and analysis of variance. RESULTS: Fifty-seven patients underwent RYGBP. Of the 57 patients, 41 were selected for analysis, 34% of whom were employed, with a mean recuperation time of 3.5 weeks. Their mean age was 32.4 years. The mean body mass index was 53.4 kg/m(2) preoperatively and 31.2 kg/m(2) at 5 years. Of the 41 patients, 27 (66%) were receiving disability and 25 (61%) attributed their disability to their morbidly obese state. At 5 years, 4 (16%) of the 25 were gainfully employed and no longer receiving public assistance. CONCLUSION: Despite successful long-term weight loss and improvement in quality of life, many morbid obesity patients do not return to gainful employment in the workforce after RYGBP. The mean body mass index was greater in the unemployed group at both 1 and 5 years, but the difference was not statistically significant. The socioeconomic impact of morbid obesity persists long after a reduction in weight and improvement in quality of life.     

A comparison of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid and super obesity: a decision-analysis model

BACKGROUND: The aim of this study was to compare laparoscopic Roux-en-Y gastric bypass (LGBP) with open Roux-en-Y gastric bypass (OGBP) to determine which approach resulted in better clinical outcomes and cost effectiveness in patients with morbid obesity. METHODS: A decision-analysis model was constructed to evaluate outcomes of LGBP versus OGBP in patients with body mass index (BMI) ranges of 35 to 49, 50 to 60, and greater than 60. Baseline assumptions for the model were derived from published reports. Sensitivity and cost-effectiveness analyses were performed to determine the optimal strategy. Success was defined as no major procedure-related complications and no long-term complications over a 1-year period after surgery. Failure of therapy was defined as either recurrent symptoms or death attributed to a surgical complication. RESULTS: In patients with a BMI of 35 to 49, LGBP failed in 14% and OGBP failed in 18% of patients, favoring LGBP alone as the dominant strategy. Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of 50 to 60, LGBP was dominant with an overall success rate of 82% as compared with OGBP (77%). Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of greater than 60, LGBP was the dominant strategy with an overall success rate of 67% compared with OGBP (63%). Sensitivity and cost-effective analysis showed that LGBP was the dominant strategy in terms of greater success and less overall morbidity and mortality for all 3 groups. CONCLUSIONS: This analysis suggests that for all BMI ranges evaluated, LGBP is preferable to OGBP. These conclusions are limited by potential selection and publication bias in the trials assessed for this analysis. These limitations can be resolved only by randomized control trials.     

Stricture dilation after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: In surgical treatment of morbid obesity, maintaining a restrictive anastomosis is key to long-range success. However, laparoscopic Roux-en-Y gastric bypass (LRYGB) may result in gastrojejunal (GJ) stricture, requiring treatment in up to 27% of patients. METHODS: This is a retrospective review of the outcome of 223 consecutive LRYGB patients. Patients developing stricture received standard endoscopic balloon dilation by the same surgeon. Stricture and nonstricture groups were compared for excess body weight loss (EBWL) at 1, 3, 6, and 12 months. RESULTS: GJ stricture requiring dilation occurred in 38 patients (17%). After dilation all patients were relieved of stricture symptoms and none required revision. By 12 months, patients with stricture had an EBWL of 86% compared with nonstrictured patients at 75%. CONCLUSION: Endoscopic balloon dilation is a safe and effective treatment option for GJ stricture. Improved weight loss occurred for patients with stricture requiring dilation.     

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass

Background The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20–100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity. Methods The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series’ end. Results are presented as mean ± standard deviation and standard statistical analysis was applied. Results Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 ± 29, 132 ± 40, 127 ± 29, and 114 ± 30 min by quartile. Mean length of stay was 2.9 ± 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach. Conclusions A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success. Presented at the Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, 26–29 April 2006     

Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery

In the treatment of morbid obesity, simple gastric restrictive methods such as silicone adjustable gastric banding, vertical banded gastroplasty, and nonadjustable gastric banding often fail to control weight in the long run or give rise to intolerable side effects. Here we review our results from conversion of such failures to Roux-en-Y gastric bypass. The study comprised 44 patients (median age 42 years, range 24 to 60 years) who underwent revision surgery in 1996 and 1997. Body mass index at revision was 35 kg/m² (range 21 to 49 kg/m²). Previous bariatric procedures included silicone adjustable gastric banding (n = 26), vertical banded gastroplasty (n = 13), and gastric banding (n = 5). The most common reasons for conversion after silicone adjustable gastric banding and nonadjustable gastric banding were band erosion (n = 12) and esophagitis (n = 11). Staple line disruption (n = 12) with subsequent weight loss failure was the primary cause after vertical banded gastroplasty. There were no postoperative deaths or anastomotic leaks. One patient underwent reexploration because of an infected hematoma. Reflux symptoms and vomiting resolved promptly. At global assessment 2 years later, 70% of the patients were very satisfied. Median body mass index had decreased to 28 kg/m² (range 18 to 42 kg/m²). No patient was lost to followup. As reported previously, failure after vertical gastric banding can be treated by conversion to Roux-en-Y gastric bypass with good results. In this study we found that failure after silicone adjustable gastric banding can be treated successfully with Roux-en-Y gastric bypass as well. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 17–20, 1998 (poster presentation).     

Predicting Maximum Roux-en-Y Gastric Bypass-Induced Weight Reduction — Preoperative Plasma Leptin or Body Weight?

Background Weight loss after bariatric surgery varies between patients, and predicting the extent thereof is often inaccurate. The aim of this study was to assess the potential of preoperative plasma leptin and body weight in predicting the maximum weight loss within 2 years after Roux-en-Y gastric bypass (RYGBP). Methods The study comprised 68 subjects (39 women, 29 men; mean age 36.4 ± 10.2 years, body weight 130.3 ± 24.8 kg, BMI 44.4 ± 6.8 kg/m²) undergoing RYGBP who were followed for 2 years. Baseline and maximum follow-up plasma leptin and weight were assessed. Results Mean maximum weight reduction of 50.5 ± 19.1 kg (38.0 ± 9.0%, range 24 – 100 kg) was noted at 15 ± 4 months after RYGBP. Baseline plasma leptin was 37.9 ± 14.5 ng/ml, and decreased to 17.4 ± 8.1 ng/ml (P < 0.001) at maximum weight reduction. No significant correlation between baseline plasma leptin and absolute or relative weight reduction or minimum body weight achieved was noted. No significant plasma leptin threshold which would be predictive for any consistent extent of weight loss was found. However, baseline body weight was a strong determinant of minimum body weight attained (r = 0.67; P < 0.01) and of maximum absolute weight reduction (r = 0.81; P < 0.01). Conclusion Preoperative plasma leptin concentration cannot be used as a predictor of weight reduction following RYGBP. Preoperative body weight is a reliable predictor of post-RYGBP weight loss.     

Comparison of totally robotic laparoscopic Roux-en-Y gastric bypass and traditional laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Laparoscopic gastric bypass is a technically demanding operation, especially when hand-sewing is required. Robotics may help facilitate the performance of this difficult operation. This study was undertaken to compare a single surgeon's results using the daVinci Surgical System with those using traditional laparoscopic Roux-en-Y gastric bypass (LRYGB) when the techniques were learned simultaneously. METHODS: From July 2004 to April 2005, the new laparoscopic fellow's first 50 patients were randomized to undergo either LRYGB or totally robotic laparoscopic Roux-en-Y gastric bypass (TRRYGB). Data were collected on patient age, gender, body mass index (BMI), co-morbidities, operative time, complication rates, and length of stay. Student's t test with unequal variances was used for statistical analysis. RESULTS: No significant differences in age, gender, co-morbidities, complication rates, or length of stay were found between the two groups. The mean operating time was significantly shorter for TRRYGB than for LRYGB (130.8 versus 149.4 minutes; P = 0.02), with a significant difference in minutes per BMI (2.94 versus 3.47 min/BMI; P = 0.02). The largest difference was in patients with a BMI >43 kg/m(2), for whom the difference in procedure time was 29.6 minutes (123.5 minutes for TRRYGB versus 153.2 minutes for LRYGB; P = 0.009) and a significant difference in minutes per BMI (2.49 versus 3.24 min/BMI; P = 0.009). CONCLUSION: Our data indicate that the use of the daVinci Surgical System for TRRYGB is safe and feasible. The operating room time is shorter with the use of the robotic system during a surgeon's learning curve, and that decrease is maximized in patients with a larger BMI. TRRYGB may be a better approach to gastric bypass when hand-sewing is required, especially early in a surgeon's experience.     

Is roux-en-y gastric bypass surgery the most effective treatment for type 2 diabetes mellitus in morbidly obese patients?

Type 2 diabetes mellitus (T2DM) has a very strong association with obesity. The aim of our study was to analyze the effects of Roux-en-Y gastric bypass (RYGB) surgery on the glucose metabolism in morbidly obese patients with T2DM. Morbidly obese patients (n = 117) with T2DM underwent measurements of fasting serum glucose and glycosylated hemoglobin (HbA1C) at baseline, 6 months, and 12 months after laparoscopic RYGB surgery. Logistic regression was used in both univariate and multivariate modeling to identify independent variables associated with complete resolution of T2DM. Twelve months after surgery, fasting plasma glucose decreased from a preoperative mean of 164 ± 55 mg/dL to 101 ± 38 mg/dL (P = .001) and HbA1C decreased from a preoperative mean of 7.7% ±1.5% to 6.0% ± 1.1% (P = .001). Resolution of T2DM was achieved in 72 patients (74%). All of the remaining 25 patients decreased the daily medication requirements. On univariate analysis, preoperative variables associated with resolution of T2DM were waist circumference, HbA1C, and absence of insulin treatment. Waist circumference (odds ratio 2.4; 95% confidence interval 1.4- 4.1; P = .001) and treatment without insulin (odds ratio 42.2; 95% confidence interval 4.3-417.3; P = .002) remained significant predictors of T2DM resolution in the multivariate logistic regression model after adjusting for covariates. Laparoscopic RYGBP resulted in significant resolution of T2DM. Peripheral fat distribution (smaller waist circumference) and absence of insulin treatment were independent and significant predictors of complete resolution of T2DM. Presented at the plenary session of the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 19, 2005 Dr. Torquati is supported by the Vanderbilt Clinical Research Award (NIH-K12RR017697-03).     

Banded Roux-en-Y gastric bypass for the treatment of morbid obesity

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective treatment for morbid obesity. The additional benefit of placing a nonadjustable band around the pouch remains to be determined. The objective of this study was to compare outcomes between banded and nonbanded LRYGB patients in a single bariatric center.MethodsA matched cohort analysis was performed between patients who had undergone banded and nonbanded (standard) LRYGB. In the banded bypass cohort, an 8 F, 6.5 cm silastic ring was placed around the proximal gastric pouch. Both cohorts were matched for age, body mass index (BMI), and anastomotic technique. Endpoints included percentage excess weight loss (%EWL), postoperative morbidity, and band-related complications.ResultsBetween January 2007 and July 2010, 134 banded LRYGB were performed (55% female, mean age 45 years). They were compared with a matched cohort of 134 concurrent nonbanded LRYGB patients (67% female, mean age 45.4 years). Mean preoperative BMI was 54.6 and 52.8 kg/m², respectively (P = .084). At 24 months postoperatively, the average %EWL was 58.6% in banded bypass patients and 51.4% in the nonbanded group (P = .015). The difference in EWL was more pronounced in super-obese patients than in those with BMI<50 (among super-obese, 57.5% versus 47.6%, P = .003; among those with BMI<50, 62.9% versus 57.9%, P = .406]. There was no difference in early (19.4% versus 19.4%) or late complications (10.4% versus 13.4%, P = .451) between banded and nonbanded LRYGB patients.ConclusionBanding the pouch during LRYGB can be performed safely and may provide better weight loss, particularly in super-obese patients. Further prospective and long-term comparative studies of this technique are warranted.     

Sexual Abuse Survivors and Psychiatric Hospitalization after Bariatric Surgery

Background Some investigators have postulated that a history of being the victim of childhood sexual abuse may impact outcome of bariatric surgery. Methods In this retrospective chart review, we examined the electronic medical records of 152 adults with morbid obesity who underwent Roux-en-Y gastric bypass and who had a weight recorded in their medical record or reported in a follow-up surgery at 2 years after the RYGBP. The purpose of this retrospective chart review was to examine the relationship between psychosocial factors assessed preoperatively and the percent of excess weight lost (%EWL) at 2 years after bariatric surgery. Results We found a high prevalence of being the victim of childhood sexual abuse (27%), adult sexual trauma (9%), and/or physical abuse (19%) at the initial evaluation. There was no association between these factors and %EWL at 2 years. However, when we examined participants’ medical records for post-operative psychiatric hospitalizations at our medical center, 8 of 11 hospitalized patients reported a history of childhood sexual abuse (73%). Conclusions History of being the victim of childhood sexual abuse is reported frequently by patients seeking bariatric surgery. Our finding that having been the victim of childhood sexual abuse may be associated with increased risk of psychiatric hospitalization after RYGBP has several clinical implications. First, we recommend that clinicians assess carefully for a history of sexual or physical abuse, and secondly, abuse survivors may need to be told that there is an increased risk of psychiatric morbidity after bariatric surgery. Finally, perhaps close monitoring of these patients may prevent psychiatric difficulties after surgery. Further research to verify these preliminary findings is clearly needed.