Psoriasis Remission after Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity

Background: Psoriasis is a chronic skin disease characterized by epithelial hyperplasia and an accelerated rate of epithelial turnover affecting approximately 1-3% of the population. Exogenous and endogenous factors including morbid obesity can increase the morbidity of psoriasis. Case Report: A 55-year-old male, who weighed 131 kg with BMI 41 kg/m², underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). He had a 15-year duration of severe psoriasis and was being medically treated. At 12 months after LRYGBP, he had lost 39 kg (68% EWL), and had complete resolution of the psoriasis and had discontinued all preoperative medications related to the disease. At 2 years after LRYGBP, psoriasis has not recurred. Conclusion: Weight loss after LRYGBP should be considered as a strategy in the treatment of severe psoriasis in morbidly obese patients.     

Adenocarcinoma of the Gastric Pouch 26 Years after Loop Gastric Bypass

A 61-year-old woman presented 29 years after loop gastric bypass with a cancer of the gastric pouch. The cancer was removed by en bloc resection of the pouch, residual stomach and involved transverse colon with Roux-en-Y esophago-jejunal reconstruction. Very few cases of gastric cancer have been reported following gastric bypass for obesity. This case represents the first reported gastric cancer arising in the gastric pouch following loop gastric bypass.     

Gastric Bezoar after Laparoscopic Roux-en-Y Gastric Bypass

Gastric bezoar is an uncommon complication following Roux-en-Y gastric bypass (RYGBP). We report two cases of bezoar formation that occurred following laparoscopic RYGBPs. In both cases, the patients presented with abdominal pain, nausea, and "frothy" vomiting. The patients were successfully treated by endoscopic fragmentation and removal of the bezoar.     

Gastric Cancer after Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed surgical procedures for morbid obesity. Several complications that may develop in the short- and long-term have been reported. We present a patient who presented with cancer in the bypassed stomach 8 years after RYGBP. Although the development of this lesion is rare and only a few cases have been reported, there are aspects worthy of discussion. Several monitoring, diagnostic and therapeutic alternatives are analyzed.     

Laparoscopic Removal of Gastric Band after Open Banded Gastric Bypass

Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials) around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical expertise is available.     

Gastric Pouch Carcinoma after Gastric Bypass for Morbid Obesity

The relationship between bariatric surgery and gastric cancer is conjectural. We present a 52-year-old woman with BMI 45 operated initially by a Lap-Band procedure complicated by gastric wall erosion of the band 9 months later. She was re-operated and the band was removed. She subsequently underwent a Roux-en-Y gastric bypass. 5 years after, gastric carcinoma was discovered in the gastric pouch. Because of varied symptoms following bariatric surgery, patients may not present promptly with symptoms related to a gastric carcinoma.     

Gastrointestinal Hemorrhage after Laparoscopic Gastric Bypass

Gastrointestinal hemorrhage is a potential perioperative complication after Roux-en-Y gastric bypass. The surgeon performing laparoscopic gastric bypass should understand the need for early recognition and management of this complication, as it can be life-threatening. This paper discusses the incidence and clinical presentation of gastrointestinal hemorrhage, mechanisms for hemorrhage, management options, and possible methods of prevention.     

Factors Determining Conversion from Laparoscopic to Open Roux-en-Y Gastric Bypass

Background: Conversion from laparoscopic to open Roux-en-Y gastric bypass (RYGBP) is expensive and time-consuming. Methods: Data from our first 1,000 laparoscopic RYGBP was entered into a database (Minnesota Database-Bariatric, Exemplo Medical). All patients met NIH criteria for bariatric surgery. Results: 41 (4.1%) of 1,000 consecutive lapRYGBPs were converted to open. Patients requiring conversion to open surgery, analyzed for predictors, revealed: 1) BMI, waist size, and weight all were significantly greater in patients converted to open bypass; 2) Gender: 9 of 109 males (8.3%) and 32 of 891 females (3.6%) were converted (Fischer's exact test, P=0.035); 3) Average age of patients converted was 44.9 compared to 41.3 in the lap group (P=0.02); 4) Conversion was required for 12 large livers (1 palpable preop, 7 had diabetes, 7 had NASH or steatosis); 5) 10 conversions for mechanical/technical reasons – 6 for inability to distend abdominal wall and/or manipulate instruments due to thickness of wall, and 2 due to loss of instruments in abdomen; 6) 9 required conversion for adhesions (2 from previous cholecystectomies with biliary leaks, and 1 from previous transverse colectomy; 7) 4 visceral injuries required conversion (2 stomach, 1 small bowel, 1 esophagus); 8) 3 hemorrhages from spleen with blood loss over 1300 ml required conversion (1 spleen removed, 6 minor not requiring open conversion); 9) 3 conversions were for anomaly/disease (1 malrotation of colon, 1 ovarian teratoma, and 1 intra-thoracic stomach). Conclusion: Steatohepatitis, diabetes mellitus, adhesions from various causes, previous bile leaks, large waist size, BMI, and weight are predictors for conversion to open surgery.     

Anastomotic Leaks after Laparoscopic Gastric Bypass

The gastrojejunostomy may be the most technically challenging step when performing laparoscopic Roux-en-Y gastric bypass. Patients who develop anastomotic leaks have increased morbidity and mortality rates. Difficulty in diagnosis is related to nonspecific systemic symptoms and limitations in most radiological studies. Our aim is to evaluate the incidence, etiology, diagnosis, management, and prevention of anastomotic leaks occurring in patients undergoing laparoscopic Roux-en-Y gastric bypass.     

Inpatient Pain Medication Requirements after Laparoscopic Gastric Bypass

Introduction: One of the benefits of laparoscopic Roux-en-Y gastric bypass (RYGBP) includes decreased pain, possibly resulting in decreased narcotic use, quicker recovery of bowel function, and shorter hospital stay. We utilize a pain management strategy for our patients undergoing laparoscopic RYGBP. We investigated this strategy as well as narcotic use and incidence of ileus. Methods: Inpatient data for patients who underwent laparoscopic RYGBP were collected. Our pain management strategy included a standing dose of ketorolac, morphine sulphate as needed, and propoxyphene hydrochloride/acetaminophen as needed after liquids were initiated. No PCAs were utilized. Results: There were 104 patients in this study. 12 patients did not undergo our pain management strategy due to reoperation (5), postoperative hemorrhage (2), and allergies (5). 2 patients required no pain medications other than ketorolac. Only 2 patients had a delay of discharge (postoperative day [POD] 3 and 5) due to lack of bowel function. An average of 11.2 mg of morphine and an average of 170 mg of propoxyphene (1.7 pills) were given by the end of POD 2. In addition, 74% of patients required no morphine on POD 2 and 48% of patients required no propoxyphene on POD 2. Bowel movements were reported in 65% patients on POD 1. Conclusions: After laparoscopic RYGBP, only a minimal amount of narcotic use is necessary. Few patients have an ileus when utilizing this pain management strategy after laparoscopic RYGBP.     

Thyrotoxicosis after Gastric Bypass

Obesity surgery is the optimal therapy for morbid obesity. A case is presented of a young woman who developed thyrotoxicosis, believed to be part of subacute thyroiditis, some days after undergoing laparoscopic Roux-en-Y gastric bypass. This clinical entity can present difficulties in differential diagnosis from potential postoperative complications. The correct diagnosis and adequate treatment made possible a favorable recovery.     

Evaluation of Intra-abdominal Pressure after Laparoscopic and Open Gastric Bypass

Background: Increased intra-abdominal pressure (IAP) postoperatively can adversely affect cardiovascular, pulmonary,and renal function. In this prospective, randomized trial, we compared the IAP in morbidly obese patients after laparoscopic and open gastric bypass (GBP) surgery. Methods: 64 patients with a body mass index of 40 to 60 kg/m² were randomized to undergo laparoscopic or open GBP.IAPs were obtained at baseline (after induction of anesthesia), immediately after the operation, and on post-operative day (POD) 1, 2, and 3. Intraoperative and postoperative fluid requirements, urine output, and creatinine clearance were recorded. Results: Demographics of the two groups were similar. IAP increased from baseline immediately after laparoscopic and open GBP (p < 0.05). IAP returned to baseline by POD 2 after laparoscopic GBP but remained elevated through POD 3 after open GBP. In fact, IAP was lower after laparoscopic _{GBP than after open GBP on POD 1, 2 and 3 (p <} 0.05).The amount of intraoperative IV fluid was similar between groups, but laparoscopic GBP required less IV fluid and facilitated higher urine output post-operatively than open GBP.There was no significant difference in creatinine clearance between groups. Conclusions: Laparoscopic GBP resulted in significantly lower IAP, less postoperative fluid required, and greater postoperative urine output than open GBP.     

Gastrointestinal Quality of Life after Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed bariatric surgical procedure for the treatment of morbid obesity (MO). Obesity-related co-morbidities reduce the quality and expectancy of life. We assessed gastrointestinal quality of life in patients following LRYGBP. Methods: The Gastrointestinal Quality of Life Index (GIQLI test) was used in this study. A higher score correlates with better quality of life. The GIQLI test was administered to 3 non-selected groups: 100 morbidly obese patients (MO group), 100 patients who had undergone LRYGBP (LRYGBP group); and a control group of 100 individuals (CO group). The CO group was composed of healthy individuals with a BMI <30 kg/m², consecutively recruited among the companions of patients who came for a surgery consultation for obesity or other pathologies. Overall test and specific dimensions scores were evaluated for each group. Results: Overall test and specific dimensions scores were significantly lower in patients with MO when compared to the CO and LRYGBP groups. There were no differences between the CO and LRYGBP groups in the overall score with regard to disease-specific digestive symptoms and the psychological and social dimensions. Conclusions: The quality of life of morbidly obese patients is worsened not only because of the presence of digestive symptoms but also because of their emotional, physical and social impact. Patients operated on by LRYGBP experience an improvement in their quality of life, with good tolerance of the anatomical changes.     

Adjustable Gastric Banding as a Revisional Bariatric Procedure after Failed Gastric Bypass

Background: Inadequate weight loss after proximal gastric bypass presents a clinical challenge to bariatric surgeons. Pouch size, stoma size and limb length are the variables that can be surgically altered. Aside from conversion to distal bypass, which may have significant negative nutritional sequelae, revisional surgery for this group of patients has not often been reported. The addition of adjustable silicone gastric banding (ASGB) to Roux-en-Y gastric bypass (RYGBP) may be a useful revision strategy because it has potential safety benefits over other revisional approaches. Materials and Methods: We report on 8 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an ASGB around the proximal gastric pouch. Bands were adjusted at 6 weeks postoperatively and beyond as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Results: Mean age and body mass index (BMI) at the time of revision were 39 ± 9.9 years and 44.0 ± 4.5 kg/m² respectively. No patients were lost to follow-up, and they lost an average of 38.1 ± 10.4% and 44.0 ± 36.3% of excess weight and 49.1 ± 20.9% and 52.0 ± 46.0% of excess BMI in 12 and 24 months respectively. Patients lost an average of 62.0 ± 20.5% of excess weight from the combined surgeries in 67 (48–84) months. The only complication was the development of a seroma overlying the area of the port adjustment in one patient. There have been no erosions or band slippages to date. Conclusions: These results indicate that the addition of an ASGB causes significant weight loss in patients with poor weight loss outcome after RYGBP. The fact that no anastomosis or change in absorption is required may make this an attractive revisional strategy. Long- term evaluation in a larger population is warranted.     

Prophylactic Cholecystectomy with Open Gastric Bypass Operation

Background: There has been controversy regarding prophylactic cholecystectomy with Roux-en Y gastric bypass. The results reported in open cases showed no significant increase in morbidity by the addition of cholecystectomy. A series of open cases were reviewed to evaluate the propriety of prophylactic cholecystectomy. Method: The records of 141 patients undergoing cholecystectomy during open gastric bypass were reviewed, documenting age, ultrasound findings and pathology. Results: Of the 141 cases analyzed, the incidence of gall-bladder pathology was 80%. 24 (17%) of the 141 patients were noted to have gallstones on preoperative ultrasound examination, and 3 (2%) showed polyps. 9 patients (6%) had gallstones at surgery with normal ultrasound. Cholesterolosis was present in 52 cases (37%) and chronic cholecystitis in 25 cases (18%). Conclusion: In view of the high incidence of gall-bladder disease (80%) already present in morbidity obese patients undergoing gastric bypass and the lack of significant morbidity in open surgery with prophylactic cholecystectomy, the addition of prophylactic cholecystectomy appears appropriate.     

Management of Acute Bleeding after Laparoscopic Roux-en-Y Gastric Bypass

Background: The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. Material and Methods: The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. Results: 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. Conclusions: The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.     

Endoscopy after Roux-en-Y Gastric Bypass: A Community Hospital Experience

Background: Roux-en-Y gastric bypass (RYGBP) is a common surgical intervention for morbid obesity. Postoperative GI symptoms are common. This study reports the endoscopic findings in symptomatic patients. Methods: Patients who developed GI symptoms after RYGBP at a single community hospital were referred for endoscopic evaluation. Standard endoscopic procedures using standard endoscopic equipment were used. Results: From April 2002 to April 2004, 23 out of 200 patients underwent 35 endoscopic procedures. All patients complained of some degree of epigastric pain, nausea and vomiting regardless of endoscopic findings. The most common endoscopic finding was ulcer disease (12 patients - 52%). Other findings included normal postoperative anatomy (7 patients - 30%), anastomotic stricture (1 patient - 4.3%), obstructed biliopancreatic limb (1 patient - 4.3%), acute gastric pouch bleed (1 patient - 4.3%), anastomotic rupture/dehiscence (1 patient - 4.3%). H. pylori was not detected in any patient. Conclusions: In patients who have had RYGBP, symptoms were a poor predictor of endoscopic pathology. Ulcer disease was the most common endoscopic finding. These ulcers were not associated with H. pylori. All ulcers responded well to oral proton pump inhibitors (PPI) and sucralfate therapy. The community gastroenterologist should be acquainted with the typical post-surgical anatomy and possible endoscopic intervention for RYGBP patients.     

Cancer in the Excluded Stomach 4 Years after Gastric Bypass

Gastric bypass is the preferred operation for treatment of morbid obesity on many services. The evaluation of the excluded stomach is always difficult and a matter of concern for the attending physician. There are only four reported cases of gastric cancer in the distal stomach after gastric bypass. We report a 57-year-old man who had intestinal metaplasia at the time of the Roux-en-Y gastric bypass 4 years ago and now developed an aggressive carcinoma in the bypassed stomach.     

Laparoscopic vs Open Roux-en-Y Gastric Bypass: A Prospective Randomized Trial

Background: The feasibility of laparoscopic Roux-en-Y gastric bypass (Lap-RYGBP) for morbid obesity is well documented. In a prospective randomized trial, we compared laparoscopic and open surgery. Methods: 51 patients (48 females, mean (± SD) age 36 ± 9 years and BMI 42 ± 4 kg/m²) were randomly allocated to either laparoscopy (n=30) or open surgery (n=21). All patients were followed for a minimum of 1 year. Results: In the laparoscopy group, 7 patients (23%) were converted to open surgery due to various procedural difficulties. In an analysis, with the converted patients excluded, the morphine doses used postoperatively were significantly (p< 0.005) lower in the laparoscopic group compared to the open group. Likewise, postoperative hospital stay was shorter (4 vs 6 days, p<0.025). Six patients in the laparoscopy group had to be re-operated due to Roux-limb obstruction in the mesocolic tunnel within 5 weeks. The weight loss expressed in decrease in mean BMI units after year was 14 and 13 after 1 ± 3 ± 3 laparoscopy and open surgery,respectively (not significant). Conclusions: Both laparoscopic and open RYGBP are effective and well received surgical procedures in morbid obesity. Reduced postoperative pain, shorter hospital stay and shorter sick-leave are obvious benefits of laparoscopy but conversions and/or reoperations in 1/4 of the patients indicate that Lap-RYGBP at present must be considered an investigational procedure.     

Open versus Laparoscopic Roux-en-Y Gastric Bypass: A Comparative Study of Over 25,000 Open Cases and the Major Laparoscopic Bariatric Reported Series

Background: Laparoscopic bariatric surgery has experienced a rapid expansion of interest over the past 5 years, with a 470% increase. This rapid expansion has markedly increased overall cost, reducing surgical access. Many surgeons believe that the traditional open approach is a cheaper, safer, equally effective alternative. Methods: 16 highly experienced "open" bariatric surgeons with a combined total of 25,759 cases representing >200 surgeon years of experience, pooled their open Roux-en-Y gastric bypass (ORYGBP) data, and compared their results to the leading laparoscopic (LRYGBP) papers in the literature. Results: In the overall series, the incisional hernia rate was 6.4% using the standard midline incision. Utilizing the left subcostal incision (LSI), it was only 0.3%. Return to surgery in <30 days was 0.7%, deaths 0.25%, and leaks 0.4%. Average length of stay was 3.4 days, and return to usual activity 21 days. Small bowel obstruction was significantly higher with the LRYGBP. Surgical equipment costs averaged ∼$3,000 less for "open" cases. LRYGBP had an added expense for longer operative time. This more than made up for the shorter length of stay with the laparoscopic approach. Conclusions: The higher cost, higher leak rate, higher rate of small bowel obstruction, and similar long-term weight loss results make the "open" RYGBP our preferred operation. If the incision is taken out of the equation (i.e. use of the LSI), the significant advantages of the open technique become even more obvious.