Bariatric Re-operations: Are They Preventable?

Background: Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. Methods: From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 ±11 years, mean original weight 151.3 ± 44.3 kg, mean BMI 58.4±16.9 kg/m2 and mean excess body weight (EBW) 94.4±43.5 kg. Mean height was 161±7.7 cm, and 15 patients were female (88.2%).The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). Results: Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP,1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. Conclusion: Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.     

Who Should Be Doing Laparoscopic Bariatric Surgery?

Background: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. Methods: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. Results: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do >25 open before laparoscopic ones; and 3) clinical trials are needed (P<0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P<0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P<0.008). Conclusions:There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships.The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.     

Chemotherapy-Associated Hepatotoxicity: Do We Need to Be Concerned?

Curative resection of liver metastases from colorectal cancer is associated with improved overall survival rates, making complete resection the goal of therapy for many patients. The addition of newer, more active chemotherapeutic regimens has prolonged patient survival in those with advanced disease and increased the number of patients eligible for surgical therapy. However, concerns regarding chemotherapy-associated liver injury may have a negative impact on the ability to offer potentially curative therapy and may increase morbidity in some patients. Specific forms of liver injury have been associated with various chemotherapeutic regimens, including steatosis and steatohepatitis with prolonged fluorouracil and irinotecan therapy, and sinusoidal injury with oxaliplatin-based regimens. While the histologic association appears likely, the contribution of chemotherapy-associated hepatotoxicity to postoperative morbidity remains ill defined. Disclosure information: Dr. Choti has served as a consultant for sanofi-aventis and Genentech.     

Workload Projections for Surgical Oncology: Will We Need More Surgeons?

Background: Over the next two decades, the US population will experience dramatic growth in the number and relative proportion of older individuals. The aim of this study was to quantify the effect of these changes on the demand for oncological procedures.Methods: The 2000 Nationwide Inpatient Sample and the 1996 National Survey of Ambulatory Surgery were used to compute age-specific incidence rates for oncological procedures of the breast, colon, rectum, stomach, pancreas, and esophagus. Procedure rates were combined with census projections for 2010 and 2020 to estimate the future utilization of each procedure.Results: By 2020, the number of patients undergoing oncological procedures is projected to increase by 24% to 51%. The bulk of growth in procedures is derived from outpatient procedures, but significant growth will also be seen in inpatient procedures.Conclusions: The aging of the population will generate an enormous growth in demand for oncological procedures. If a shortage of surgeons performing these procedures does occur, the result will inevitably be decreased access to care. To prevent this from happening, the ability of surgeons to cope with an increased burden of work needs to be critically evaluated and improved.Presented at the Society of Surgical Oncology meeting, Los Angeles, California, March 2003.     

Surgical Site Infections Following Bariatric Surgery in Community Hospitals: A Weighty Concern?

Background  

Although obesity is a well-known risk factor for surgical site infection (SSI), specific risk factors for SSI among obese patients undergoing bariatric surgery (BS) have not been well-defined.     

Assessing Marijuana Use in Bariatric Surgery Candidates: Should It Be a Contraindication?

Research has demonstrated negative effects of both alcohol and tobacco use after bariatric surgery. However, no research to date has examined effects of cannabis use after bariatric surgery, even though cannabis is the most commonly used illicit drug in the USA. Literature review reveals that many practitioners generalize from data regarding alcohol abuse to all substances. Further, many screening protocols fail to differentiate between varying levels of cannabis use. The current report aims to (1) review the relevant literature on marijuana use and its potential consequences among bariatric patients, (2) discuss relevant problems and gaps in this literature, and (3) make preliminary recommendations regarding the assessment and treatment planning of bariatric candidates who disclose marijuana use.     

Vitamin D Deficiency Before Bariatric Surgery: Should Supplement Intake Be Routinely Prescribed?

Background

Before bariatric surgery, we demonstrate a 96% rate of vitamin D deficiency in morbidly obese French patients: should supplement intake be routinely prescribed? We conducted a prospective observational study to demonstrate the prevalence of vitamin D deficiency in morbidly obese patients awaiting bariatric surgery.

Methods

Clinical and biological data were collected on 50 successive patients.

Results

Data showed vitamin D deficiency in 96% (25-OH vitamin D = 31 ± 13 nmol/l), with a cut-point of 50 nmol/l. Secondary hyperparathyroidism was found in 44% of patients with hypovitaminosis D (parathyroid hormone (PTH), 59?±?24 pg/ml). Impaired PTH level concerned 89% of this group, considering the cut-point at 30 pg/ml. No significant correlation appeared between vitamin D and calcium or phosphate levels.

Conclusions

Before surgery, we demonstrated a higher incidence of vitamin D deficiency in morbidly obese French patients as compared to the general population. The incidence was also higher than previous American studies. Screening for hypovitaminosis D may routinely be considered in morbid obesity. Long-term observation is, however, needed to assess the advantages and potential side effects of systematic vitamin D supplements.

     

Destiny of Failed Adjustable Gastric Bandings: Do All the Patients Need Further Bariatric Surgery?

Purpose

The number of laparoscopic adjustable gastric banding (LAGB) removal has increased throughout the years. The aim of the study was to evaluate the outcomes in patients undergoing LAGB removal with or without further bariatric surgery.

Materials and Methods

Data prospectively collected from consecutive patients undergoing LAGB removal from 2008 to 2016 at our institution were retrospectively analyzed. Obesity-related comorbidities, complications, and body mass index (BMI) before removal and at 1-year follow-up were evaluated.

Results

A total of 156 patients were included in the study. Seventy-six patients had further surgery (SURG group): 55 underwent laparoscopic sleeve gastrectomy (LSG) and 21 laparoscopic Roux-en-Y gastric bypass (LRYGB). Eighty patients underwent only LAGB removal (No-SURG group). The mean BMI was lower in the No-SURG group (33.9 vs 36.3 kg/m², p =?0.0055). Reasons for removal were different in the two groups: dysphagia, frequent vomiting, and LAGB-related complications requiring urgent treatment occurred more commonly in the No-SURG group (p <?0.05): 71.3 vs 51.3%, 67.5% vs. 38.2%, 28.8% vs. 6.6%, respectively. At 1-year follow-up, 96.3% of No-SURG patients regained weight after LAGB removal; two (2.5%) patients showed new-onset comorbidities, four (5%) needed adjustments in pharmacological therapy, and four (5%) complained from persistence of GERD symptoms. Additional surgery provided significant weight loss: the mean %TWL was 23.7% after LSGs and 27.2% after LRYGBs.

Conclusions

LAGB is associated with a high rate of reoperation. Further bariatric surgery after LAGB removal should be considered due to weight regain, persistence of GERD symptoms, and new-onset comorbidities.

     

Predicting Bariatric Surgical Outcomes: Does Preoperative Weight Gain Correlate with Lesser Postoperative Weight Loss?

Background: This study is a retrospective analysis of 76 patients who underwent vertical banded gastroplasty (VBG), in order to determine whether preoperative weight gain correlates with lesser postoperative weight loss. Methods: Patients were divided into two groups: those patients who did not gain a significant amount of weight during the preoperative period (group 1), and those patients who gained greater than 2.5% of their preoperative BMI during the preoperative period (group 2). There were 59 patients in group 1 and 17 patients in group 2. Results: Patients in group 1 had an average follow-up of 374 days and lost an average of 37.5 kg. The patients in group 2 had an average follow-up of 379 days with an average weight loss of 39.3 kg. Conclusion: Linear regression analysis was performed and supported the finding that preoperative weight gain is not predictive of lesser postoperative weight loss.     

Extremity Soft Tissue Sarcoma Resections: How Wide Do You Need to Be?

Background  

Sarcomas require a wide margin of resection including a cuff of normal tissue to minimize the risk of local recurrence. The amount of tissue that constitutes a wide margin is unclear in the literature.