Myasthenia Gravis Improvement after Laparoscopic Roux-en-Y Gastric Bypass

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m², and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.     

Gastric Bypass Surgery in a Paraplegic Morbidly Obese Patient

The complications of spinal cord injury are exaggerated with obesity, and create complex medical and socioeconomic issues. Despite the well-documented advantages of bariatric surgery in reducing the morbidity of obesity, this option has not been routinely offered to obese patients with spinal cord injuries. We describe the first case of a morbidly obese male with a spinal cord injury who underwent a successful Roux-en-Y gastric bypass.     

Laparoscopic Gastric Bypass in a Patient with Malrotation of the Intestine

The increased prevalence of morbid obesity is associated with an increased prevalence of obesity co-morbidities. Bariatric surgery is generally the only effective treatment. Gastric bypasses are the most common bariatric operation in many countries, and more than half are performed laparoscopically. We discuss the challenges encountered in performing laparoscopic gastric bypass and cholecystectomy in a morbidly obese patient who was found to have malrotated small and large bowel when the procedure started. In the absence of past gastrointestinal symptoms and investigations, there is no way of diagnosing this anomaly preoperatively. However, when such a problem is posed at the time of surgery, it is safe to perform the planned operation if the surgeon has experience and skills in advanced laparoscopic techniques.     

Gastrointestinal Symptoms are More Intense in Morbidly Obese Patients and are Improved with Laparoscopic Roux-en-Y Gastric Bypass

Background: Currently there are few reports comparing gastrointestinal (GI) symptoms in the morbidly obese versus control subjects or the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on such symptoms. Methods: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient undergoing LRYGBP, and the questionnaire was re-administered 6 months postoperatively. Six symptom clusters (abdominal pain, irritable bowel [IBS], reflux, gastroesophageal reflux disease [GERD], sleep disturbances, and dysphagia) were compared in the following manner using Students t-test: 1) Control vs. Preop, 2) Control vs Postop, and 3) Preop vs Postop. Results are expressed as mean ± standard deviation, significance P=0.05. Results: 43 patients (40 female and 3 male, age 37.3 ± 8.6, BMI 47.8 ± 4.9) completed the questionnaire preoperatively, and 36 patients (34 female, 2 male, BMI 31.6 ± 5.3) completed the questionnaire 6 months postoperatively, for a response-rate of 84%. Abdominal pain, IBS, reflux, GERD and sleep disturbance symptoms were significantly worse in preop versus controls. Dysphagia was not different. Postop vs preop scores revealed abdominal pain, IBS, GERD, reflux, and sleep disturbance symptoms to be improved significantly. Dysphagia was not significantly different. Only dysphagia was worse when comparing postoperative to controls. No other symptom cluster was significantly different in controls vs postoperative. Conclusions: Morbidly obese patients experience more intense GI symptoms than control subjects, and many of these symptoms return to control levels 6 months after LRYGBP. Dysphagia is equivalent to control subjects preoperatively but increases significantly after LRYGBP. This data suggests another quality-of-life improvement (relief of GI symptoms) for morbidly obese patients. Further follow-up is needed to document the long-term reduction of GI symptoms.     

Gastric Bypass for Morbidly Obese Patients with Established Cardiac Disease

Background: Bariatric surgery has often been avoided in patients with known cardiac disease because of the risks inherent in this patient population. This study was done to evaluate both the risks and benefits of Roux-en-Y gastric bypass (RYGBP) in morbidly obese patients with established cardiac disease. Methods: Data were analyzed to compare preoperative with postoperative co-morbid cardiac risk factors, peri-operative and postoperative complications, and change in body mass index (BMI) in 77 consecutive patients who had a preoperative diagnosis of cardiac disease and underwent RYGBP between March 1998 and January 31, 2006. Findings were compared to a concomitant control group without cardiac disease. Results: The preoperative presence of cardiac disease was manifested primarily as coronary artery disease (CAD) (45 patients) or as congestive heart failure (CHF) (32 patients). Of the patients with CAD, 60% had diabetes, 91% had hypertension and 39% had hyperlipidemia. 58% had one or more prior invasive cardiac procedures. In the CHF group, 50% had diabetes, 71% had hypertension and 44% had hyperlipidemia. The average length of stay was 3.7 days for CAD patients and 3.3 days for CHF compared to 3.0 days for controls. All co-morbid conditions were improved, and no patient died from cardiac disease. However, one patient died as a complication of GI bleeding, one patient subsequently underwent revascularization and another underwent stenting. Other complications up to 5 years postoperatively were frequent but seldom life-threatening. Conclusion: RYGBP surgery in patients with existing cardiac disease appears to have acceptable risk and is effective in reducing the co-morbid conditions of diabetes, hypertension, hyperlipidemia, sleep apnea and arthritis, but longer term data are needed.     

Intestinal Malrotation in a Patient Undergoing Laparoscopic Gastric Bypass

Intestinal malrotation is an anomalous disorder resulting from the incomplete rotation and fixation of the midgut during embryonic development. Although most patients present early in life with symptoms of bowel obstruction, others remain asymptomatic throughout their lives. We report the case of a 40-year-old morbidly obese woman with no significant past medical history, found to have intestinal malrotation on initial laparoscopic exploration for gastric bypass.     

Efficacy and Safety of Patient-Controlled Analgesia for Morbidly Obese Patients Following Gastric Bypass Surgery

Background: Adequate postoperative pain control is important to reduce potential cardiopulmonary complications. It is often difficult to determine dosages of narcotics for morbidly obese patients following Rouxen-Y gastric bypass (RYGBP) due to respiratory depression. Individualization of analgesic therapy, patient-controlled analgesia (PCA), can provide optimal dosage for pain control and minimize the side-effects. Method: 25 morbidly obese patients who received PCA with morphine sulfate following RYGBP. PCA settings we re as follows: morphine, 20 μg/kg of ideal body weight, 10-minute lock out interval and 80% of a calculated amount for a 4-hour limit.We measured arterial blood gas, heart rate, mean arterial pressure, arterial oxygen saturation, respiratory rate, opioid amount, patient satisfaction, visual analog pain scale (VAS), and the incidence of nausea, vomiting, pruritus and sedation. Results: Average morphine usage was 44.2±28.7 mg during the day of surgery (DOS); 49.1±27.4 mg during POD (postoperative day) #1; and 36.6±22.8 mg during POD#2 (p < 0.01). 24 patients were satisfied with their pain control on POD#1. VAS was 5.4±2.1 on the day of surgery, but remained below 4 thereafter. Arterial oxygen saturation and vital signs were maintained without significant changes. 5 patients experienced mild sedation on the day of surgery and 3 patients experienced mild sedation on POD#1. 1 patient experienced nausea and vomiting and 4 patients had pruritus; however, none required treatment. Conclusion: PCA is safe and effective for morbidly obese patients following RYGBP.     

Use of Fibrin Sealant in Laparoscopic Gastric Bypass for the Morbidly Obese

Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the USA. Anastomotic leak is one of the devastating complications in this operation. By using fibrin sealant around the anastomosis, surgeons can achieve better hemostasis around the suture-line and prevent or decrease the incidence of anastomotic leaks. This paper discusses the biological and clinical evidence for use of fibrin sealant in laparoscopic gastric bypass.     

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.     

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.     

Prevalence of Non-alcoholic Steatohepatitis in Morbidly Obese Subjects Undergoing Gastric Bypass

Background: Obesity is the most common cause of non-alcoholic steatohepatitis (NASH). This is a prospective study to determine the incidence and severity of NASH in patients undergoing Roux-en-Y gastric bypass (RYGBP) for morbid obesity. We also examined the relationship between NASH and potential risk factors. Methods: In 48 consecutive patients at RYGBP, a core liver biopsy was obtained from the left lateral segment. A single liver pathologist reviewed the histology for steatosis, ballooning/disarray, necroinflammation, and fibrosis. Results: 84% of patients were female, and average BMI was 51. 18% had WHR >1. The following risk factors were present: DM 16%; hyperlipidemia 61%; HTN 47%; and abnormal LFTs 18%. 90% had abnormal liver histology, and 56% qualified for the diagnosis of NASH. Only DM and abnormal LFTs were found to be significantly related to NASH. Conclusions: NASH is a common co-morbidity of obesity and requires systemized grading and staging to develop accurate knowledge of the incidence, severity, natural history and impact of weight loss.     

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.     

Prevalence of Subclinical Hypothyroidism in a Morbidly Obese Population and Improvement after Weight Loss Induced by Roux-en-Y Gastric Bypass

Background:There are many studies concerning thyroid function in obesity, and some of them describe higher TSH levels in obese subjects. Few studies evaluated long-term changes in thyroid function caused by weight loss after bariatric surgery. Our aims were to evaluate the prevalence of subclinical hypothyroidism (SH) in a morbidly obese population and to analyze the effect of weight loss induced by Roux-en-Y gastric bypass (RYGBP) on TSH and thyroid hormone (TH) levels. Methods: TSH, free thyroxine (fT4) and total triiodothyronine (T3) levels were analyzed before and 12 months after RYGBP in patients with grade III or grade II obesity with co-morbidities. Subjects taking TH and/or with positive antithyroid antibodies and/or with overt hypothyroidism were excluded. Results: 72 subjects (62F/10M), with mean age 39.6±9.8 years and mean BMI 53.0±10.4 kg/m² were studied. The prevalence of SH before RYGBP was 25% (n=18). There was a significant post-surgical decrease in BMI in the whole population, as well as in SH patients. In the SH group and normal TSH group, there was a decrease in TSH and T3, but not in fT4. TSH was not correlated with initial BMI or percent change in BMI. TSH concentrations reached normal values in all SH patients after RYGBP. Conclusion: Our data confirm that severe obesity is associated with increased TSH. The decrease in TSH was independent of BMI, but occurred in all SH patients. A putative effect of weight reduction on the improvement of SH in all patients may be an additional benefit of bariatric surgery.     

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.     

Zinc Nutritional Status of Morbidly Obese Patients Before and After Roux-en-Y Gastric Bypass: A Preliminary Report

Background: Previous researchers have found that the nutritional zinc status in obese and diabetic subjects is altered: low zinc concentrations in plasma and erythrocytes with high urinary zinc excretion were observed. This study assessed the influence of the Roux-en-Y gastric bypass (RYGBP) on the plasma, erythrocyte and urinary zinc concentrations before the beginning of the mineral supplementation. Methods: 24 morbidly obese patients were studied before and 2 months after RYGBP (the period in which the patients were still not ingesting mineral supplements). Fast blood sample, 24-hour urine, and 3-day food records were collected in the pre- and postoperative phases. Zinc concentration in the samples was analyzed by flame atomic absorption spectrophotometry, and dietary analysis of the food records were performed using the software Virtual Nutri with the inclusion of zinc concentration in the database for regional foods. Results: Pre- and postoperative results were respectively: plasma 68.0 and 66.3 μg/dL; erythrocytes 36.6 and 43.8 μg/g Hb; urine 884.7 μg/24h and 385.9 μg/24h; and zinc intake 10.5 and 6.7 mg/day. Conclusion: These results suggest that RYGBP changed mainly the zinc erythrocyte and urinary concentrations. As expected, the zinc intake was lower in the postoperative phase, which in the medium and long term, could cause problems for the patients.     

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.     

Small Bowel Obstruction and Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass

Background: Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Methods: Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention.There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Results: Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. Conclusion: SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.     

Laparoscopic Roux-en-Y Gastric Bypass in a Patient with Situs Inversus

We report the case of a morbidly obese patient with situs inversus totalis presenting for laparoscopic Roux-en-Y gastric bypass (RYGBP). The operative technique is detailed and we recommend the use of a mirror image approach to all parts of the operation. Consequently, the operative time is only moderately longer than usual. Laparoscopic RYGBP can be safely performed in patients with situs inversus.     

Facilitated Vertical Gastric Pouch Construction for Gastric Bypass

Background: Efforts to simplify and reduce surgical risk of gastric pouch construction in super obese patients have led to technical changes which are described. Methods: Operative technique of vertical gastric pouch construction and hand-sewn Roux gastrojejunostomy are described. Results: 171 patients with average BMI = 55 have undergone gastric bypass with the modified technique, a majority with double stapling of the gastric pouch. Staple-line dehiscence is reduced and operative morbidity is limited. Conclusions: Technical changes described have shortened operative time, reduced intraoperative frustrations, and produced limited postoperative morbidity.     

Changes in Insulin Sensitivity in Morbidly Obese Patients with or without Metabolic Syndrome after Gastric Bypass

Background: We evaluated the medium term changes in insulin sensitivity in morbidly obese patients with and without metabolic syndrome before and after Roux-en-Y gastric bypass (RYGBP) with silastic ring (Capella-Fobi). Methods: A longitudinal, clinical intervention study was conducted in 40 patients between 18 and 65 years old, with obesity class II and III (BMI ≥35-52 kg/m²), divided into 2 groups: no metabolic syndrome (NMS, n=21) and metabolic syndrome (MS, n=19). Anthropometric measurements, biochemical tests and classification of MS according to the NCEP criteria, were performed pre-operatively and at 3 and 6 months postoperatively. Results: In the preoperative period, 87% of the patients presented obesity class III (BMI 47±5 kg/m²) while 13% of the patients had obesity class II (37±2 kg/m²), and 19 patients (47.5%) presented MS. In the preoperative period, there were no differences among patients with MS and NMS in relation to the anthropometrics and body composition measurements. However, triglyceridemia, glycemia and insulinemia were higher in the MS group compared to the NMS group (P<0.05), although there was no difference in HOMA between the groups. HDL-cholesterol was lower in the MS group (p<0.05). In both postoperative study periods, all patients had significant reduction of anthropometric variables, body composition and biochemical variables. There were no differences between MS and NMS (p>0.05) groups. However, insulinemia decreased more in the postoperative period in the MS group compared to the NMS group (p<0.05). MS frequency in the MS group diminished to 26% after 3 postoperative months and no patient presented features of MS after 6 months postoperatively. Conclusions: Based on these observation: 1) patients of class II and III obesity present peripheral resistance to hyperinsulinemia without hyperglycemia; 2) RYGBP is able to reduce anthropometric measurements and body composition in a similar way for patients who have, or have not, MS; 3) there is rapid normalization of biochemistry of carbohydrates and lipids; 4) patients with previous MS lose the criteria needed for this diagnosis after 6 postoperative months.