Early Changes in Ghrelin following Roux-en-Y Gastric Bypass: Influence of Vagal Nerve Functionality?

Background Roux-en-Y gastric bypass (RYGBP) effectively produces massive weight reduction, improving health in morbidly obese patients. The mechanisms for the weight loss, and the fate of the excluded gastric mucosa, are not fully clarified. To what extent the appetite-stimulating gastric peptide ghrelin is affected remains controversial. Methods Circulating concentrations of ghrelin, pancreatic polypeptide (PP), pepsinogen I (PGI) and gastrin were examined in 15 morbidly obese patients (median BMI 45 kg/m²) preoperatively, and on days 1, 2, 4, 6 and at months 1, 6 and 12 after RYGBP. Results Ghrelin levels fell on postoperative day 1 and increased after 1 month to preoperative levels, and rose further at 6 and 12 months. PP concentrations decreased on day 1 and subsequently returned to preoperative levels. PGI levels peaked transiently the first days after surgery and subsequently declined to lower than preoperative levels. Gastrin levels were gradually reduced postoperatively. Conclusion Ghrelin and PP fall transiently after surgery, possibly due to vagal dysfunction, and ultimately, as weight loss ensues, ghrelin secretion increases to higher than preoperative levels. The RYBGP procedure affects the gastric mucosa, as reflected by a transient increase in circulating PGI, and subsequently, the mucosa in the excluded stomach is at rest, as shown by low levels of PGI and gastrin.     

Argon Plasma Coagulation and Gastric Bypass—A Novel Solution to Stomal Dilation

A patulous gastro-enterostomy after gastric bypass is a common cause of poor restriction and poor weight loss. Revisional surgery is an option but may be hazardous. This case report highlights the use of argon plasma coagulation by flexible endoscopy to reduce stomal size, improve restriction, and avoid revisional surgery.     

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

Background

The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure—signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)—frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure.

Methods

Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons.

Results

No difference in major complication rate was seen (2.8 vs. 2.3 %, p?=?0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien–Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p?<?0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36–110).

Conclusions

Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.

     

Dysphagia Lusoria: A Complication Following Gastric Bypass Surgery?

A 23-year-old Caucasian female presented with progressive dysphagia beginning 5 months following laparoscopic gastric bypass for morbid obesity. She was diagnosed with an aberrant right subclavian artery and underwent a combined right supraclavicular approach and left thoracotomy for resection, with reimplantation of the vessel to the ipsilateral carotid artery. The patient had complete resolution of symptoms.     

Deep venous thrombosis prophylaxis: Are guidelines being followed?

Introduction: The purposes of the present study were to determine whether patients in The Canberra Hospital are receiving appropriate Deep Venous Thrombosis (DVT) prophylaxis, and to ascertain the awareness of appropriate treatment by clinicians. Methods: Part 1 of the present study comprised of a point prevalence study of The Canberra Hospital inpatients. Patients were assessed for the risk of their developing DVT. The prophylaxis they were receiving was documented. In Part 2 of the present study, clinicians at The Canberra Hospital filled out a questionnaire that outlined three case scenarios. They were required to identify the risk group and appropriate prophylaxis for each group. Consultants, registrars and junior medical officers were assessed separately. Results: The results of Part 1 of the present study showed that the majority of inpatients in The Canberra Hospital are not receiving appropriate prophylaxes according to international guidelines. Graduated compression stockings are rarely used, and often ineffectively applied. All groups performed poorly in Part 2 of the present study. Participants were frequently unable to identify the risk group for a particular scenario. There was also confusion regarding the appropriate prophylaxis for a particular risk group. Discussion: Deep Venous Thrombosis is a major problem among hospitalized patients. However, despite its importance, there is a lack of appropriate prophylaxes being instituted. This, together with the poor performance of the participating clinicians in Part 2 of the present study, indicate that there are significant problems in The Canberra Hospital regarding DVT prophylaxes and that steps need to be taken to overcome these problems.     

Serious cerebral venous thrombosis: can we use fibrinolytic?

We report a case of thrombosis of superior sagittal and cavernous sinuses treated by direct instillation of fibrinolytic agents via selective catheterization. Despite risk of bleeding related to the pathology and treatment, no adverse side-effect occurred. This report is unusual regarding the poor initial clinical patient's condition with dilated and unreactive pupil. The good neurologic outcome warrants aggressive treatment in the most severe forms of cerebral venous thrombosis.     

Are Laparoscopic Gastric Bypass After Gastroplasty and Primary Laparoscopic Gastric Bypass Similar in Terms of Results?

Background  

This retrospective study compares the results of primary gastric bypass (PGB) versus secondary gastric bypass (SGB) performed after gastroplasty.     

Laparoscopic Roux-en-Y Gastric Bypass:Transoral Or Transgastric Anvil Placement?

Background: Laparoscopic techniques have been used to perform the Roux-en-Y gastric bypass (RYGBP). The gastrojejunostomy may be constructed using an end-to-end anastomosis (EEA) stapler. Most reports describe passing the EEA anvil transorally using an esophagogastroscope and a pullwire technique. Method: We describe problems experienced using this technique and present an alternative method. Results: Esophageal injury may occur during laparoscopic RYGBP (LRYGBP) using the transoral anvil placement technique. When the anvil is retrieved into the gastric pouch, the anvil may become lodged at the cricopharngeus muscle. Dislodgment can be problematic and time-consuming. We present a case of mild esophageal injury which occurred during transoral anvil placement. The patient had transient postoperative dysphagia and recovered without sequelae. We present an alternative method in which the anvil is passed through a gastrotomy. Conclusion: Transgastric anvil placement alleviates the need for endoscopy, thereby saving time and resources.This technique eliminates the potential for esophageal injury. The transgastric anvil placement technique has proven reliable. The transgastric method may make the LRYGBP operation safer and easier to perform.     

Is Weight Loss Better Sustained with Long-Limb Gastric Bypass in the Super-Obese?

Background  

While some studies have shown that long-limb gastric bypass with Roux limb length of 150 to 200 cm can attain better weight loss outcomes in super-obese patients (BMI >50 kg/m²) than the standard limb gastric bypass with Roux limb length of 100 to 150 cm, other studies have not shown similar findings. Additionally, no study has demonstrated the optimal length of the Roux limb that will result in ideal weight loss. The purpose of this study is to compare the long-term weight loss and weight regain of standard limb length (SLL) and long limb length (LLL) gastric bypass in patients with BMI >50 kg/m².     

Primary axillary-subclavian venous thrombosis: is aggressive surgical intervention justified?

Multimodal (thrombolysis, surgical decompression, venous reconstruction, oral anticoagulation) treatment of primary axillary-subclavian venous thrombosis was reviewed to assess the impact of venous patency on functional outcome. Since 1996, 7 patients (6 men, 1 woman) of ages 16-53 years (mean 33 years) presented with symptomatic acute axillosubclavian venous thrombosis as a result of a recent athletic or strenuous arm activity. Five patients had undergone previous (>2 weeks) catheter-directed thrombolysis and venous angioplasty. Diagnostic contrast venography followed by repeat catheter-directed thrombolysis demonstrated abnormal (residual stenosis [n=6] or occlusion [n=1]) axillosubclavian venous segments in all patients. Surgical intervention was performed at a mean interval of 7 days (range 1-19 days) after thrombolysis and consisted of thoracic outlet decompression with scalenectomy and 1st rib resection via a paraclavicular (n=4) or supraclavicular (n=3) approach. Medial claviculectomy or cervical rib resection was performed in 2 patients. Concomitant venous surgery was performed in all patients to restore normal venous patency by circumferential venolysis (n=7) and balloon catheter thrombectomy (n=3), or vein-patch angioplasty (n=2), or endovenectomy (n=5), or internal jugular transposition (n=2). Postoperative venous duplex testing beyond 1 month identified recurrent thrombosis in 4 patients despite therapeutic oral anticoagulation. Subsequent venous recanalization was documented in 3 patients. Poor functional outcome was associated with an occluded venous repair and extensive venous thrombosis on initial presentation. A patent or recanalized venous repair present in 6 of 7 patients was associated with good functional outcome and may justify multimodal intervention in patients with primary axillosubclavian effort thrombosis presenting with recurrent thrombosis and significant residual disease after thrombolysis.     

Robotic Roux-en-Y Gastric Bypass,is it Safer than Laparoscopic Bypass?

Background

Along with the development of technology, robotic approach is being performed for laparoscopic Roux-en-Y gastric bypass (LRYGB). Some literatures reported same or better peri-operative outcomes with the robotic procedure. The aim of this study is to compare our experience in robot-assisted LRYGB (RA-LRYGB) with LRYGB in terms of peri-operative outcomes.

Methods

From January 1, 2012 to April 30, 2014, a total of 270 patients underwent LRYGB by one surgeon at a single institution. Of these, 64 cases were done robotically. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure.

Results

The 64 RA-LRYGB patients had a mean age of 45.9?±?10.0 years (range, 23–67) and a mean preoperative body mass index (BMI) of 48.4?±?7.9 kg/m² (range, 33.8–76.4). The 207 LRYGB patients had a mean age of 45.0?±?10.7 years (range, 21–67) and a mean preoperative BMI of 48.4?±?8.1 kg/m² (range, 34.0–80.4). These two groups were clinically comparable. Mean length of hospital stay was 3.0?±?4.1 days (range, 1–19) in RA-LRYGB patients, significantly longer than 1.6?±?1.7 days (range, 1–17) in LRYGB patients (p?<?0.01). Thirty-day readmission rate was 9.3 % (n?=?6) in the RA-LRYGB group and 6.8 % (n?=?14) in the LRYGB group. Higher leak rate was noticed in RA-LRYGB patients at 7.8 % (n?=?5), compared to 0.5 % (n?=?1) in LRYGB patients (p?<?0.01). All the leaks occurred at the pouch level in the RA-LRYGB group, while one leak from the LRYGB group occurred at the gastrojejunal anastomosis site.

Conclusions

Robot-assisted Roux-en-Y gastric bypass may result in higher leak rate at the pouch level, when compared to that of laparoscopic procedures.

     

Compulsive Eating and Gastric Bypass Surgery: What does Hunger have to do with It?

Background: Binge eating and other patterns of disordered eating in obese patients need further investigation. In a previous study by this author, one-third of patients presenting for bariatric surgery met strict criteria for Binge Eating Disorder. It is important to clarify the role of such eating behaviors on outcome of surgery to determine whether treatments targeted specifically at these behaviors and associated psychological issues can improve surgical outcome. The aim of this paper is to raise awareness of the range of disordered eating patterns in bariatric patients, describe an approach used, and discuss issues reported by patients after surgery. Methods: Patients completed questionnaires before surgery (QWEP, BES, BDI) and were seen for a pre-surgery mental health evaluation. High risk patients were identified and invited to attend a postsurgery group (CBT approach) as a preventive measure to help them deal with eating patterns as well as emotional adjustment. Results: Disordered eating patterns can persist after surgery. While surgery may decrease actual physical hunger and reduce physical capacity for food, it is still possible to eat compulsively,although the patterns may change somewhat due to the surgical procedure. Conclusion: Since long-term weight maintenance depends on post-operative changes in eating behaviors, it is important to identify patients at risk for a range of disordered eating patterns so that a comprehensive treatment plan that targets the eating disturbances and associated psychological components can be implemented.     

Laparoscopic Single-Anastomosis Duodenal–Jejunal Bypass with Sleeve Gastrectomy (SADJB-SG): Short-term Result and Comparison with Gastric Bypass

Laparoscopic duodeno–jejunal bypass with sleeve gastrectomy (DJB-SG) has been introduced as a novel metabolic surgery from Asia recently. It provides benefits of avoiding the risk of remnant gastric cancer, minimization of malnutrition from duodenal switch. Here, we introduce the technique of single-loop anastomosis duodeno–jejunal bypass with sleeve gastrectomy (SADJB-SG) and compare with other gastric bypass surgeries. Fifty morbid obese patients underwent our novel procedure, laparoscopic SADJB-S from 2011 to 2013. Operative complication, weight loss, and diabetes remission were followed. All procedures were completed laparoscopically. The mean operative time was 181.7?±?38.4 min, and the mean hospital stay was 3.8 days. Three minor early complications (6 %) were encountered but no major complication was noted. There was no significant difference in perioperative parameters between the SADJB-SG and gastric bypass except a longer operation time. The mean BMI decreased from 38.4 to 25.4 at 1 year after surgery with a mean weight loss of 32.7 % which is higher than gastric bypass. Laparoscopic SADJB-SG appears to be an ideal metabolic/bariatric surgery, whereas the efficacy is non-inferior to gastric bypass.     

Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.