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.     

Pharmaceutical Savings after Gastric Bypass Surgery

Background: Clinically severe obesity (CSO) is a surgically treated disease.The Roux-en-Y gastric bypass (RYGBP) has been used to treat patients with CSO and has resulted in an improvement in co-morbidities. We speculated that after a period of weight loss, patients would require less medication, resulting in cost-savings to both the patient and the insurance company, as well as an overall gain in health. Method: A retrospective study was performed which involved the first 100 patients who had undergone RYGBP at a community-teaching hospital. Analysis of the data was conducted by the Wilcoxon signed rank test. Results: 64 patients met our inclusion criteria and had adequate follow-up data available. The mean BMI was 57 kg/m² (range 36.6- 85.4 kg/m²), the female to male ratio was 4:1 (51:13), and the mean age was 44 years (range 27-64). The average monthly medication expenditure was reduced from $317 (SEM 47.25, range $23.12-$1801.19) preoperatively, to $135 (SEM 35.35, range $0.00-$1122.72) postoperatively. This reduction is significant (P <0.01). Conclusion: Weight loss after RYGBP leads to a significant reduction in medication expenses. These medication savings offset the costs of the initial procedure and represent permanent financial savings for the patient and society.     

Non-closure of Defects during Laparoscopic Roux-en-Y Gastric Bypass

Background The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that nonclosure of defects with our particular technique would not cause a significant clinically evident internal hernia rate. Methods All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (<4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations. Results here was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia. Conclusions Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.     

Disappointing Weight Loss among Shift Workers after Laparoscopic Gastric Bypass Surgery

Background Shift work is an increasingly common employment structure in the United States and has been associated with increased rates of obesity and the metabolic syndrome. Shift work can necessitate altered patterns of sleep, eating, and activity over traditional work schedules. We investigated the effects of shift work on postoperative weight loss in bariatric surgery patients. Methods A retrospective chart review of 389 patients undergoing laparoscopic Roux-en-Y gastric bypass was conducted. Shift workers were identified as patients with at least 2 years of employment primarily outside the hours of 8:00 am to 5:00 pm preoperatively and without return to a traditional schedule in the period up to 1 year postoperatively. Trends in excess body weight loss were categorized and compared between the shift workers and the nonshift workers in the cohort. Student’s t-test was used for statistical analysis. Results 8 shift workers were identified in the cohort. They had an average age of 45.9 years and preoperative BMI of 54.6, as compared to an age of 43.6 and BMI of 47.0 for the non-shift-workers in the cohort. 75% were female, compared to 83% for the non-shift-workers. Average postoperative excess weight loss for the shift workers was significantly lower than in the non-shift-workers: 29.9% vs 43.8% (P < .01) at 3 months, 46.4% vs 61.3% (P < .01) at 6 months, and 56.5% vs 76.8% (P < .01) at 12 months. Conclusions The postoperative period in bariatric surgery requires significant adjustments in patients’ lives. The potential for altered sleep physiology, reduced quantity of sleep, altered hormonal balance, increased tendency to disordered eating, and poorer quality of food intake, are all possible etiologies for substandard weight loss outcomes in shift workers undergoing bariatric surgery. Additional care should be taken in preoperative counseling and postoperative management of these patients.     

Psychological Outcome Two Years after Restrictive Bariatric Surgery

Background An essential outcome criterion of obesity surgery besides weight loss is the improvement of medical and psychological health status. Both dimensions influence quality of life. This study evaluates depressive symptoms, self-esteem and health-related quality of life 2 years after bariatric surgery. Methods 149 patients (47 males (32%), 102 females (68%), mean age 38.8 ± 10.3 years) were assessed by standardized questionnaires before and 1 and 2 years after gastric restrictive surgery. Results Mean BMI pre-surgery was 51.3 ± 8.4 kg/m2. BMI decreased significantly to 38.6 ± 6.8 kg/m2 at 1 year and to 37.9 ± 7.4 kg/m2 at 2 years after surgery. Statistical analyses revealed a significant decrease in depressive symptoms and a significant improvement in selfesteem and the physical dimension of health-related quality of life. Pre-surgery, 40.5% (n = 62) of the patients suffered from depressive symptoms of clinical relevance. These depressive symptoms persisted in 17.7% (n = 27) 1 year and in 16.4% (n = 25) 2 years after surgery. Conclusion Parallel with a considerable weight loss after bariatric surgery, important aspects of mental health such as depressive symptoms and selfesteem improved significantly. These effects appear 1 year after surgery, but do not seem to change considerably afterwards.     

Symptomatic Hypoglycemia Complicating Pregnancy Following Roux-en-Y Gastric Bypass Surgery

Symptomatic hypoglycemia is a known consequence of gastric bypass surgery, which is being performed with increased frequency in reproductive-aged women. A 36-year old woman presented at 24 weeks’ gestation, 39 months following Roux-en-Y gastric bypass (RYGBP), with new onset symptomatic hypoglycemia. Lightheadedness and syncope coinciding with postprandial glucose levels of 34–57 mg/dL responded to dietary modifications. Following RYGBP physiologic changes of pregnancy may precipitate clinically significant hypoglycemia in the previously asymptomatic patient.     

Three-Year Follow-Up Study of Retrocolic versus Antecolic Laparoscopic Roux-en-Y Gastric Bypass

Background Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity. Methods 33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the followup over 36 months. Results In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46 kg/m2 to 32 kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45 kg/m2 to 34 kg/m2 after 36 months (P = 0.276). Conclusion The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic technique.     

Roux-en-Y Gastric Bypass after Failed Vertical Banded Gastroplasty

BACKGROUND: Vertical banded gastroplasty (VBG) was the restrictive procedure of choice for many years. However, VBG has been associated with a high rate of long-term failure. We reviewed our experience of conversion of failed VBG to Roux-en-Y gastric bypass (RYGBP). METHODS: The data on all patients undergoing conversion of failed VBG to RYGBP were reviewed. Failed VBG was defined as insufficient weight loss (BMI > 35 kg/m2) and/or VBG-related complications. RESULTS: We performed 24 conversions from VBG to RYGBP. Median age was 40 +/- 8 years (range 28 to 61). Preoperative weight was 111 +/- 25 kg (range 85 to 181), and median BMI was 41 +/- 8 kg/m2 (range 30 to 69 kg/m2). Indication for conversion was: VBG failure in 18 patients and VBG complications in 6 patients. A gastrectomy (total or proximal) had to be performed in 5 cases (21%). The conversion was performed by laparoscopy in 13 cases. Postoperative complications occurred in 4 patients (16.7%). There were no leaks, nor mortality. Postoperative BMI was 31 kg/m2 (range 25 to 42) at a median follow-up of 12 months (range 3 to 36 months). The average percentage of excess weight loss was 62% at 1 year. CONCLUSION: VBG has been associated with a significant reoperation rate for failure and/or complications. Conversion to RYGBP is effective in terms of weight loss and treatment of complications after VBG. Gastrectomy and resection of the staple-line could reduce such complications as leaks and mucocele. Although technically challenging, conversion of VBG to RYGBP is feasible, with acceptable morbidity and no mortality. The conversion is feasible laparoscopically.     

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.     

Laparoscopic Roux-en-Y Gastric Bypass Surgery on Morbidly Obese Patients with Hypothyroidism

Background It is well known that obesity is accompanied by changes in thyroid function. Hypothyroidism is associated with increased body weight. The aim of this study was to evaluate the operative outcomes, weight loss, and the effect of weight loss on thyroid function in morbidly obese patients with hypothyroidism who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods A retrospective review of 20 morbidly obese female patients with hypothyroidism and on thyroid replacement therapy who underwent LRYGB between January 2003 and August 2006. Results Mean preoperative body mass index (BMI) was 47.6 kg/m² (range 38–58.5 kg/m²). Average patient age was 44.5 years (range 21–66 years). There was one early complication (pneumonia). Late complications included one death, three anastomotic strictures, and one small bowel obstruction. The patients were followed for a mean of 13.5 months (range 3–24 months). Their mean excess body weight loss was 13 kg (22%), 24.4 kg (39.4%), 33.2 kg (63.3%), 38.4 kg (65%), 41.7 kg (70%), and 43 kg (73%) at 1, 3, 6, 9, 12, and 24 months, respectively. Change in a mean BMI was the same regardless of the patient preoperative and postoperative thyroxine dose. Hypothyroidism resolved in 5(25%) patients, improved in 2(10%) patients, unchanged in 8(40%) patients, and worsened in 5 (25%) patients. Most of the five whose hypothyroidism worsened had thyroid autoimmune disease. Conclusions Hypothyroidism appears to improve in the vast majority of morbidly obese patients who undergo LRYGB, except for those whose thyroid disease is autoimmune in nature.     

Treatment of Gastrogastric Fistula after Roux-en-Y Gastric Bypass: Surgery Combined with Gastroscopy

A 53-year-old male who had previously undergone an open gastric bypass (Capella-Fobi) developed a gastrogastric fistula during the late postoperative course. Because he regained weight and had a stomal ulcer difficult to control, it was decided to submit him to revisional surgery. At laparotomy, a retrogastric approach plus gastroscopy permitted easy identification and closure of the fistula. The patient is doing well and losing weight after this reoperation.     

Drain-Associated Intestinal Obstruction after Laparoscopic Gastric Bypass

A rare cause of intestinal obstruction after laparoscopic Roux-en-Y gastric bypass (RYGBP) is reported. A 42-year-old woman developed nausea, vomiting and dilated loops of small bowel upon commencing oral intake the day after RYGBP surgery. A CT scan demonstrated a loop of bowel twisting around the abdominal drainage catheter. After removal of the catheter, the patient’s symptoms immediately resolved and her subsequent course was uneventful. We suggest avoidance of drainage catheters after uncomplicated laparoscopic RYGBP.     

Metabolic Syndrome after Laparoscopic Bariatric Surgery

Background  Metabolic syndrome (MS) is common among morbidly obese patients undergoing bariatric surgery. The aim of this study was to assess the impact and predictors of bariatric surgery on the resolution of MS. Methods  Subjects included 286 patients [age 44.0 ± 11.5, female 78.2%, BMI 48.7 ± 9.4, waist circumference 139 ± 20 cm, AST 23.5 ± 14.9, ALT 30.0 ± 20.1, type 2 diabetes mellitus (DM) 30.1% and MS 39.2%] who underwent bariatric surgery. Results  Of the entire cohort, 27.3% underwent malabsorptive surgery, 55.9% underwent restrictive surgery, and 16.8% had combination restrictive–malabsorptive surgery. Mean weight loss was 33.7 ± 20.1 kg after restrictive surgery (follow up period 298 ± 271 days), 39.4 ± 22.9 kg after malabsorptive surgery (follow-up period 306 ± 290 days), and 28.3 ± 14.1 kg after combination surgery (follow-up period 281 ± 239 days). Regardless of the type of bariatric surgery, significant improvements were noted in MS (p values from <0.0001–0.01) as well as its components such as DM (p values from <0.0001–0.0005), waist circumference (p values <0.0001), BMI (p values <0.0001), fasting serum triglycerides (p values <0.0001 to 0.001), and fasting serum glucose (p values <0.0001). Additionally, a significant improvement in AST/ALT ratio (p value = 0.0002) was noted in those undergoing restrictive surgery. Multivariate analysis showed that patients who underwent malabsorptive bariatric procedures experienced a significantly greater percent excess weight loss than patients who underwent restrictive procedures (p value = 0.0451). Percent excess weight loss increased with longer postoperative follow-up (p value <0.0001). Conclusions  Weight loss after bariatric surgery is associated with a significant improvement in MS and other metabolic factors.     

Predictors of Outcome after Gastric Bypass Surgery

Background Weight loss outcome predictions after gastric bypass (GBP) surgery based on individual findings have shown relatively little consistency. The present study took a more comprehensive approach, utilizing extensive pre-surgery interview and psychological test data both individually and in composite predictors. Methods Pre-surgery data were obtained for 131 morbidly obese patients on a 273-item interview and 5 psychological assessment instruments, and weight loss measures (simple weight change and BMI change) were obtained at a mean of 12.8 months following surgery. Results Individual predictor variables based on existing research findings showed expected but mostly nonsignificant correlations with weight loss. Optimal composite predictor variables were constructed for 4 general areas of pre-surgery assessment as represented in the literature: physical/medical health, psychological health, interpersonal support, and eating disorder. Each composite variable significantly predicted weight loss, and together they showed multiple correlations of .50 with simple weight change and .54 with simple BMI change. Conclusions Sustained weight loss after GBP was related to a rather wide range of pre-surgery variables, each of which made a small contribution, but composite variables grounded in the general literature provided more effective prediction. It is cautioned that continued success after ≥2 years could be dependent on yet other variables, with a possible contribution from some post-surgery factors.     

Abdominal Actinomycosis: a Rare Complication after Laparoscopic Gastric Bypass

A 33-year-old, morbidity obese woman underwent a laparoscopic Roux-en-Y gastric bypass in November 2004. She presented 18 months later with a history of recurrent pain in the upper region of the abdomen and severe vomiting. Radiologic and endoscopic evaluations revealed wall thickening in the transverse colon and a solid tumor near the liver. Therefore, a sonography-guided biopsy of the tumor was performed. Cytopathological examination revealed actinomycosis. Thus, therapy with penicillin was started, after which the parameters associated with the infection decreased. The symptoms persisted, however, and the decision was made to operate on the patient to resect the abdominal masses. Nearly 90% of the masses could be removed. Histological analysis showed a fibro-productive inflammation with an actinomycotic etiology. Antibiotic therapy with penicillin was continued for 6 months. Actinomycosis must be considered in the differential diagnosis of patients with abdominal mass, wall thickening of the intestine, and other such symptoms, including abdominal pain following bariatric surgery, even many years after the intervention.     

Rhabdomyolysis After Bariatric Surgery by Roux-en-Y Gastric Bypass: A Prospective Study

Background  Obesity is a worldwide epidemic associated to comorbidities and increased mortality. Because it is chronic and recurrent and has little response to clinical measures, surgical treatment (bariatric surgery) is a therapeutic option frequently used. Different surgical complications have been associated with this type of procedure, but there is little knowledge about neuromuscular complications. Among the latter, rhabdomyolysis (RML), described a few years ago, has not been well characterized to date. Methods  We have studied 22 consecutive patients who underwent surgical treatment with open Roux-en-Y gastric bypass (RYGBP) for morbid obesity in a university hospital. A database was created including the following information of each patient: gender, age, body mass index (BMI), comorbidities, surgical time, pre- and postoperative creatine phosphokinase (CPK) dosages, and neuromuscular symptoms after surgery. The main outcome measure was the frequency of RML using CPK dosage after 24 h of surgery. RML was diagnosed as an increase of more than five times the superior limit of normal range of CPK. Results  Fourteen women and eight men were evaluated, with median age of 39.9 ± 11.2 years, median BMI of 52.4 ± 8.0 kg/m² and mean surgical time of 253.2 ± 51.9 min. The mean value of postoperative CPK was 7,467.7 ± 12,177.1 IU/L, being greater than 5,000 IU/L in 40.9% of the patients. RML was diagnosed in 17 (77.3%) patients. No patient had renal failure caused by RML, but there was one death (4.5%) related to abdominal infectious complications. Clinical neuromuscular symptoms occurred in 45% of patients, and muscular pain was the most common one, especially in gluteus region. Comparative analyzes between patients without and with RML diagnosis showed that longer surgical time (p = 0.005), and occurrence of neuromuscular symptoms (p = 0.04) were more common in the latter. Conclusion  The results of this study are similar to few other investigations and confirm that RML in open bariatric surgery with RYGBP (Capella) is a common complication. A longer surgical time can be involved in RML pathogenesis, and muscular pain is suggestive of RML occurrence.     

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.     

Evaluation of the Clinical Pathway for Laparoscopic Bariatric Surgery

Background Clinical pathways (CP) are comprehensive systematized patient care plans for specific procedures. The CP for morbid obesity was implemented in our department in September 2005. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. Methods A study was conducted on all the patients included in the CP since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year before the implementation of the CP. We analyzed the mean cost per procedure before and after CP implementation. Results Evaluation was made of a series of 49 consecutive patients who underwent surgery over the period of 1 year before the development of the CP and met the accepted inclusion criteria. The mean length of hospital stay was 7.95 days, and the mean cost per procedure before pathway implementation was 5,270.37 (±2,251.19) euros. One year after the implementation of the pathway, 70 patients were included. The mean length of hospital stay of the patients included in the CP was 5.1 days. The degree of compliance with stays was 71.4%. The most frequent reason for noncompliance was patient-dependent causes. The mean cost in the series of patients included in the CP was 4,532 (±1,753) euros. Conclusion The CP for morbid obesity reduced both variability in professional care patterns and hospital costs; justifying the work involved in its development and implementation.     

Insulinoma Misdiagnosed as Dumping Syndrome after Bariatric Surgery

Background: Late dumping syndrome is a possible side-effect of gastric bypass. Hypoglycemic symptoms may develop 3-4 hours after certain types of foods.There may exist patients, however, who present hypoglycemia in the absence of dumping syndrome. The presence of only mild symptoms of hypoglycemia may make the evaluation of these patients difficult and delay the identification of other possible sources of hyperinsulinemia, including an insulinoma. Case Report: A 65-year-old woman underwent gastric bypass for continued weight gain and morbid obesity. After surgery, the patient had repeated episodes of hypoglycemia, diagnosed at follow-up as late dumping syndrome. The persistence of hypoglycemic episodes after nutritional counseling and modifications in the feeding pattern led to consideration of an autonomous source of hyperinsulinemia, and MRI and CT identified insulinoma. After a laparotomy and pancreatic tumor resection, she remains free of symptoms. Conclusion: Hypoglycemic episodes after obesity surgery are not always related to dumping syndrome. The persistence of hypoglycemia in spite of nutritional counseling should raise the possibility that there may exist other causes. Insulinoma, the most common cause of endogenous hyperinsulinemia, should be investigated in these patients, since it is a tumor that can be cured.