Fatal Fulminant Pancreatitis After Laparoscopic Gastric Bypass Surgery

Current widespread application of laparoscopic techniques in Roux-en-Y gastric bypass (RYGBP) is making surgical safety an increasingly important issue. We report one case that resulted in death due to postoperative fulminant acute pancreatitis after laparoscopic RYGBP was performed when this procedure was still relatively new in China. The patient was a chronically obese 19-year-old male. Weight loss medications had been ineffective, and preoperative body mass index was 40.7. Preoperative examination revealed moderate steatohepatitis. Laparoscopic RYGBP (LRYGBP) was performed. Early manifestations of clinical shock appeared 13 h after the laparoscopic surgery. A second laparoscopic examination showed small-vessel hemorrhage at the posterior wall of the jejunojejunal anastomosis, with blood clot formation resulting in Roux limb and afferent loop obstruction. Fulminant acute pancreatitis developed in the patient 18 h after the second surgery. The patient died 15 days later from systemic multiorgan insufficiency. LRYGBP (postcolon) is a technically demanding procedure for surgeons who are not experienced in this operation. In addition, surgical tolerance is reduced in morbidly obese patients. Therefore, special care should be taken during surgery, and hemostasis must be achieved at all bleeding sites. Increased perioperative surveillance allows for early detection and management of severe complications.     

Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass

Background Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. Methods Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. Results Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). Conclusion In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity.     

Laparoscopic Repair of a Staple-line Disruption after an Open Uncut Roux-en-Y Gastric Bypass

The technique of gastric bypass has undergone an evolution over the last 20 years, although it is often individualized based on surgeon preference. Whereas many surgeons divide and separate the gastric pouch from the distal bypassed stomach, some surgeons choose to staple, but not cut and separate the pouch. Staple-line failure resulting in a gastrogastric fistula and weight regain is a worrisome complication. We discuss a case of a patient with an obvious staple-line failure, which resulted in complete weight regain. She underwent laparoscopic repair and was discharged on postoperative day 1. Laparoscopic repair of a staple-line disruption after an open uncut gastric bypass is feasible. Presented at the World Congress of the International Federation for the Surgery of Obesity, Sydney, Australia, August 31, 2006.     

Early Experience with Intraluminal Reinforcement of Stapled Gastrojejunostomy During Laparoscopic Roux-En-Y Gastric Bypass

Background The use of extraluminal staple-line buttressing material during laparoscopic Roux-en-y gastric bypass has shown the potential to reduce staple-line leak and bleeding. We herein present our early experience with intraluminal reinforcement of linear-cutting stapled gastrojejunal anastomosis with the use of bioabsorbable glycolide copolymer staple-line reinforcement. Methods Laparoscopic Roux-en-Y gastric bypass was performed in 80 consecutive non-randomized morbidly obese patients. Gastrojejunal anastomosis was performed using a linear-cutting stapler without staple-line reinforcement in 40 patients (group A), while in the other 40 patients (group B), gastrojejunostomy was performed using a linear cutting stapler with intraluminal reinforcement material (bioabsorbable glycolide copolymer). Demographic data were collected. The rate of gastrojejunal anastomotic leak, bleeding, and stricture was determined. Results There was a statistically significant reduction in bleeding complications between the two groups (15% bleeding in group A vs. no bleeding in group B, P value = 0.0255). Stricture rate was higher in-group A (10% group A vs. 2.5% in group B); however, the difference was not statistically significant (P value = 0.2007). None of our patients developed a gastrojejunal leak. Conclusion Intraluminal reinforcement of gastrojejunal anastomosis during laparoscopic gastric bypass is safe and feasible. The use of intraluminal bioabsorbable glycolide copolymer staple-line reinforcement significantly reduces the incidence of gastrojejunal bleeding.     

Clinical Features of Rhabdomyolysis After Open and Laparoscopic Roux-en-Y Gastric Bypass

Background Rhabdomyolysis (RML) is caused by muscle injury, this may cause kidneys overload and lead to acute renal failure (ARF). The risk factors for RML in bariatric surgery (BS) are operative time (OT) >4 h and high BMI. The frequency of RML in BS varies from 12.9 to 37.8%. This study has the objective of describing the characteristics associated with RML and ARF in BS. Methods We studied retrospectively 114 patients submitted to BS. Criteria for RML were CPK level >950 IU/l (five times the normal value). The variables were BMI, OT, age, intraoperative hydration and diuresis, CPK, creatinine, arterial hypertension, peripheric vascular disease, diabetes, open and laparoscopic techniques—inclusion criteria: patients submitted to gastric bypass; exclusion: renal failure and statins use. Results RML incidence was 7%. The factors associated with RML in the bivariate analysis were hepatic steatosis, high BMI, high weight, higher excess weight, and prolonged OT. The risk factor for RML in the multivariate analysis was BMI ≥ 50 kg/m². When the OT was below 2 h the incidence of RML was zero, but this was not significant in the multivariate analysis. The factors associated with a higher risk of CPK elevation (multivariate analysis) were hypertension and open technique. Conclusion BS is safe, with low incidence of RML/ARF. High BMI is associated with a higher risk of RML. Probably a longer OT is associated with a higher risk of RML not statistically demonstrated in this study. The factors associated with a higher risk of CPK elevation were hypertension and open technique.     

Comparison of Recovery Time after Open and Laparoscopic Gastric Bypass and Laparoscopic Adjustable Banding

Background: Laparoscopy is believed to reduce recovery time and patient discomfort following bariatric surgical operations. This study tests that hypothesis. Methods: 60 randomly selected bariatric surgery patients, consisting of 20 open Roux-en-Y gastric bypass (RYGBP), 19 lap RYGBP, and 21 laparoscopic adjustable banding, were studied. Outcome measures including hospital length of stay (LOS), days to return to normal activity, days to surgical recovery, and pain medication usage were defined by the patients' subjective responses to a retrospective questionnaire. Overall differences among the three surgeries were first determined using the Kruskal-Wallis test, and then individual comparisons were made between each of the three pairs of operations using a Wilcoxon rank-sum test when a significant difference existed. Results: Patients reported an average LOS of 3.45 days following open RYGBP, 2.47 days following lap RYGBP, and 1.33 days following Lap-Band? surgery. There was little difference in return to normal activity, with open RYGBP patients reporting a 17.55 day delay in return to normal activity, and lap RYGBP reporting an 18.16 day delay. In contrast, Lap-Band? patients responded that the delay was only 7.24 days. Days to recovery were reported to be 29.05 for open RYGBP patients, 21.68 for lap RYGBP patients and 15.81 for Lap-Band? patients. Hospital days (P=0.0002), days to normal activity (P=0.0115), and days to recovery (P<0.0001) differed significantly among the surgery types. Lap and open RYGBP did not differ significantly regarding days to resumption of normal activities. Open RYGBP and banding differed significantly regarding days to recovery (P <0.001). Conclusions: Lap-Band? patients returned to normal activity levels earlier than gastric bypass patient's irrespective of approach. Lap-Band? patients also reported recovering from surgery significantly sooner than open RYGBP patients. Perceived differences in recovery time between open and laparoscopic RYGBP patients did not affect their time to resumption of normal activity.     

Gender-Related Difference in Postoperative Pain After Laparoscopic Roux-En-Y Gastric Bypass in Morbidly Obese Patients

Some evidence exist to suggest that women experience more pain and require more medication than men to achieve a similar state of analgesia. However, this was not studied in morbidly obese patients. The study evaluates the effect of gender on postoperative pain and analgesic consumption in the first 24 h in morbidly obese patients who undergo laparoscopic Roux-En-Y gastric bypass surgery (RYNGPB). One hundred thirty obese adult patients who underwent elective RYNGPB were included in the study. Postoperative pain scores were compared using a numeric rating scale, at intervals (0, 15, 30, 45, 60, 90, and 120 min), and following discharge from the postanesthesia care unit (PACU) at 6, 12, and 24 h. Titrated morphine dose during the 2-h PACU stay and pethidine consumption in the subsequent 24 h were measured. One hundred fourteen patients completed the study (59 females and 55 males). Female patients had higher initial pain scores and higher morphine consumption (10.1?±?3.1 mg) than male patients (7.2?±?4.5 mg), P?=?0.0001. Following PACU discharge, there was no gender difference in pain scores or analgesic consumption. Pethidine consumption in male patients during the first day was 97.8?±?35.1 versus 98.1?±?61.6 mg among female patients, P?=?0.9729. Female patients had higher initial pain score and morphine consumption than men in the immediate postoperative period, but that difference disappeared after discharge from PACU.     

Laparoscopic Roux-en-Y Gastric Bypass for Morbidly Obese Chinese Patients: Learning Curve,Advocacy and Complications

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) involves a combination of both restrictive and mal-absorptive mechanisms and has become the procedure of choice for patients with morbid obesity in Western countries. However, its efficacy remains uncertain in Asian populations. We report our pilot experience with LRYGB in a Chinese population. METHODS: Between August 2005 and February 2007, 100 morbidly obese patients received LRYGB. We evaluated the learning curve for the operation, its efficacy in weight reduction, and its postoperative complications. RESULTS: Surgical time reached a plateau after about 50 cases, decreasing from 216 min for the initial 50 patients to 105 min for the final 50. The conversion rate from laparoscopic to open surgery was 2%. The mean percent body mass index loss was 33.9% after 12 months. Twenty-four complications occurred in 18 patients, but most resolved with conservative treatment without mortality. Patients with advanced age (P = 0.04) or hypertension (P = 0.03) were at increased risk for complications leading to prolonged surgical times and hospital stays. The complication rate declined as technical expertise increased. CONCLUSION: In Chinese patients with morbid obesity, LRYGB is promising procedure because of its acceptable learning curve, good efficacy, and low complication rate.     

Laparoscopic Gastric Bypass with Intestinal Malrotation

Intestinal malrotation is a congenital anomaly occurring in one of 500 live births. It typically presents during the first months of life, but in rare instances, it can persist undetected into adulthood when it is identified during a radiographic or surgical procedure. We present a case of intestinal malrotation discovered at the time of laparoscopic Roux-en-Y gastric bypass (LRYGBP), detail the technical aspects needed to be incorporated to complete the operation, followed by a literature review of this rare clinical scenario. Incomplete malrotation is not a contraindication to performing a LRYGBP for morbid obesity.     

Gastric Migration and Strangulation After Adjustable Gastric Banding

We present a case of gastric strangulation 6 months after laparoscopic adjustable gastric banding (LAGB). The 45-year-old woman presented to our emergency department with acute left upper quadrant abdominal pain. Initial upper gastrointestinal studies after emergency department presentation showed no flow through the gastric band and an unusual air/fluid level just above the band, not communicating with the proximal pouch. The patient underwent emergency diagnostic laparoscopy, during which strangulation of a portion of the gastric fundus was identified. During this laparoscopic procedure, the band was removed, and the strangulated portion of stomach was resected using a laparoscopic stapling device. The patient had an uneventful postoperative course and was discharged 6 days after surgery. We present this case as an example of a rare late acute complication resulting from LAGB, which should be recognized and treated surgically on an emergent basis.     

Gastric Cancer After Laparoscopic Adjustable Gastric Banding

A 63-year-old woman with BMI 46 underwent laparoscopic gastric banding. In the standardized follow-up after 14 and 24 months, the GI series and gastroscopy showed no pathological signs. The patient had hematemesis 32 months after gastric banding, followed by symptoms of obstruction, for which a laparotomy was performed. At operation, peritoneal carcinomatosis due to gastric cancer was found. Symptoms after bariatric procedures can be similar to symptoms of gastric or esophageal cancer. We believe that yearly postoperative gastroscopy is indicated to exclude pathological changes.     

Surgical Management of Gastro–Gastric Fistula After Divided Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Gastro–gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial. Methods A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006. Results Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3–27). Morbidity in six patients (25%) was caused by pneumonia, n = 2; wound infection, n = 2; staple-line bleed, n = 1; and subcapsular splenic hematoma, n = 1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients. Conclusion Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures. This paper was presented at the SSAT Poster Presentation session on May 21st 2007 at the SSAT Annual Meeting at Digestive Disease Week, Washington (poster ID M1590).     

Incidence of Lower Limbs Deep Vein Thrombosis After Open and Laparoscopic Gastric Bypass: A Prospective Study

Background Lower limbs deep vein thrombosis (DVT) and pulmonary embolism (PE) are major causes of morbidity and mortality and are even higher in bariatric patients. The longer operative time and higher immobility in these patients increase the DVT risk. Although deaths after bariatric surgery have been reported, there is no consensus regarding the prophylaxis of DVT. This study’s objective is to determine the incidence of lower limbs DVT in patients submitted to Roux-en-Y-gastric bypass (RYGBP) under prophylaxis by enoxaparin. Methods Patients with body mass index (BMI) equal to or higher than 35 kg/m² who submitted to RYGBP by laparotomy or laparoscopy using 40 mg/day of enoxaparin for 15 days were recruited between October 2004 and August 2005. Individuals with previous DVT and heparin allergy were excluded. Patients were tested for DVT using color Doppler ultrasound performed before surgery and on the second and fifth weeks after surgery. Results The study population included 136 patients, with 126 concluding the protocol. There were 79% (100/126) of female patients aged 19 to 65 years old, with mean of 40 years SD = 10 and BMI between 35 and 61 kg/m², mean of 43 kg/m² (SD = 5). All patients who submitted to RYGBP were divided as 55% (69/126) by laparoscopy and 45% (57/126) by laparotomy. The incidence rate of lower limbs DVT was 0.79% (1/126). Conclusion The low incidence rate of DVT found in our study suggests that obesity might not be a major risk factor for venous thromboembolism in patients submitted to RYGBP.     

Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass

Background  Internal hernias have been described after laparoscopic Roux-en-Y gastric bypass (LRYGB) as a major problem. Thus, many routinely close defects during LRYGB. In our technique, we do not close any defects. We hypothesize that not closing the defects would not cause a significant internal hernia rate diagnosed during reoperations. Methods  Patients who were reoperated after LRYGB were included in this study. Only patients who had a laparoscopic or open exploration focused on inspecting for internal hernias are reported here. The LRYGB technique that was utilized included an antecolic, antegastric gastrojejunostomy, minimal division of the small bowel mesentery, a long jejunojejunostomy performed with three staple lines, adequate division of the omentum, and placement of the jejunojejunostomy above the colon in the left upper quadrant. Results  There were a total of 387 patients who had LRYGB from 2002 to 2007 utilizing this particular technique. Fifty-four patients had a reoperation at an average of 24 (Range: 1–60) months postoperatively. The procedures were abdominoplasty, cholecystectomy, diagnostic laparoscopy, and lysis of adhesions. While two patients had a defect present, no patient had an internal hernia despite aggressive attempts to diagnose one. Conclusions  Internals hernias are not common after our particular method of LRYGB. Before adopting and advocating routine closure, surgeons should consider the surgical technique and the true associated incidence of internal hernias. We do not recommend routine closure of these defects with our technique. Presented in part at International Federation for the Surgery of Obesity annual meeting; August 2006; Sydney, Australia.     

Intra-operative Pneumothorax Complicating Laparoscopic Roux-en-Y Gastric Bypass

Background: Intra-operative pneumothorax (PTX) is an infrequent complication of laparoscopic surgery. Most cases are attributed to CO₂ diffusion across congenital diaphragmatic defects and resolve spontaneously. We report a case of PTX during a laparoscopic Roux-en-Y gastric bypass (LRYGBP). When applied to this specific patient population, the current literature recommendations for the management of intra-operative PTX are questioned. Material and Methods: A retrospective chart review of 400 consecutive LRYGBP procedures performed over a 30-month period revealed 1 case of PTX (0.025%). Results: A bulging left diaphragm, hypotension, bradycardia, decreased pO₂, and elevated EtCO₂ and airway pressures, were noted early in the case. She initially responded to conservative management but required multiple subsequent hospital admissions for pulmonary complications. Conclusions: Pneumoperitoneum-induced PTX during laparoscopic bariatric surgery is a rare complication. Its treatment must be based on the potential underlying cause, with consideration of these patients' often delicate pulmonary status. In stable patients, where the PTX is attributed to diaphragmatic or hiatal dissection, expectant treatment is appropriate. In all other situations, however, we believe that tube thoracostomy is indicated. An algorithm for treatment of PTX in laparoscopic bariatric surgery is proposed. It follows the dictum of maintaining extreme vigilance and a low threshold for aggressive intervention in this group of patients.     

Early Gastrointestinal Hemorrhage after Laparoscopic Gastric Bypass

Background: Early gastrointestinal (GI) hemorrhage after open gastric bypass has been infrequently reported. The aim of this study was to examine the incidence of early GI hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP), its presentation, and possible treatment options. Methods: A retrospective review of 5 patients who developed early postoperative GI hemorrhage after LRYGBP was performed.The charts were reviewed for demographics, clinical presentation, diagnostic evaluation, and treatment. All patients underwent a transected LRYGBP with creation of the gastrojejunostomy anastomosis with a circular stapler and the jejunojejunostomy anastomosis with a linear stapler. Results: Of the 155 patients in our database who underwent LRYGBP, 5 (3.2%) developed early clinical GI hemorrhage. There were 2 males with an average age of 40 years. Clinical presentations of GI hemorrhage were hematemesis (2 patients), bright red blood per rectum (1 patient), melena (1 patient), and hypotension (1 patient). A diagnostic study (nuclear scintigraphy) was performed in only 1 of 5 patients. 3 of 5 patients were managed nonoperatively; 2 patients required fluid and blood resuscitation, and the other patient was managed without blood transfusion. The onset of hemorrhage in these 3 patients occurred 24 hours postoperatively or later. 2 of 5 patients required operative intervention for control of hemorrhage. The onset of hemorrhage or hypotension in these 2 patients occurred within 12 hours after surgery. The sites of hemorrhage were at the gastric remnant staple-lines in 1 patient and at the gastrojejunostomy and gastric remnant staple-lines in the other patient. Conclusion: Early GI hemorrhage is a potential complication after transected LRYGBP. Early reoperative intervention should be performed for patients with hemodynamic instability and patients with early onset of hemorrhage after surgery.     

Serum Magnesium Status After Gastric Bypass Surgery in Obesity

Background  Roux-en-Y gastric bypass (RYGBP) has become a common surgical procedure to treat morbid obesity. Furthermore, it strongly reduces the incidence of type 2 diabetes and mortality. However, there is scant information on how magnesium status is affected by RYGBP surgery. Previous bariatric surgery methods, like jejunoileal bypass, are associated with hypomagnesemia. Methods  Twenty-one non-diabetic morbidly obese patients who underwent RYGBP were evaluated before and 1 year after surgery and compared to a matched morbidly obese control group regarding serum magnesium. Groups were matched regarding weight, BMI, abdominal sagittal diameter and fasting glucose, blood pressure, and serum magnesium concentrations before surgery in the RYGBP group. Results  The serum magnesium concentrations increased by 6% from 0.80 to 0.85 mmol/l (p = 0.019) in the RYGBP group while a decrease by 4% (p = 0.132) was observed in the control group. The increase in magnesium concentration at the 1-year follow-up in the RYGBP group was accompanied by a decreased abdominal sagittal diameter (r ² = 0.32, p = 0.009), a lowered BMI (r ² = 0.28, p = 0.0214), a lowered glucose concentration (r ² = 0.28, p = 0.027) but not by a lowered insulin concentration (p = 0.242), a lowered systolic (p = 0.789) or a lowered diastolic (p = 0.785) blood pressure. Conclusion  RYGBP surgery in morbidly obese subjects is characterized by reduced visceral adiposity, lowered plasma glucose, and increased circulating magnesium concentrations. The inverse association between lowered central obesity, lowered plasma glucose and increased magnesium concentrations, needs further detailed studies to identify underlying mechanisms.