The Effect of Roux-en-Y Gastric Bypass on Gastroesophageal Reflux Disease in Morbidly Obese Chinese Patients

Background  The prevalence of gastroesophageal reflux disease (GERD) is increasing in Eastern and Western countries. Obesity is recognized as a risk factor of gastroesophageal reflux disease. However, little information is available on the prevalence of gastroesophageal reflux disease in morbidly obese Chinese patients. The aim of this study was to compare the prevalence of GERD in Chinese patients with morbid obesity and age- and sex-matched controls, and we also assessed the effect of Roux-en-Y gastric bypass on reflux symptoms and erosive esophagitis. Methods  Between November 2006 and February 2008, 150 morbidly obese Chinese patients underwent laparoscopic Roux-en-Y gastric bypass. Gastroesophageal reflux disease questionnaires and esophagogastroduodenoscopy results were assessed in all cases before surgery. The prevalence of reflux symptoms and erosive esophagitis was compared with the prevalence in a database of 300 age- and sex-matched controls. We also compared baseline and postoperative characteristics at 12 months after operation. Results  Patients with morbid obesity had higher frequencies of reflux symptoms (16% vs. 8%, P = 0.01) and erosive esophagitis (34% vs. 17%, P < 0.01) than those of controls. Twelve months after laparoscopic Roux-en-Y gastric bypass, 26 patients received follow-up evaluations. In addition to substantial weight loss, the prevalence of reflux symptoms and erosive esophagitis decreased significantly after operation (19.2% vs. 0%, P = 0.05, and 42.3% vs. 3.8%, P < 0.01, respectively). Conclusions  Gastroesophageal reflux disease is pervasive in Chinese patients with morbid obesity and Roux-en-Y gastric bypass substantially improves not only the reflux symptoms but also the erosive esophagitis.     

Pregnancy Following Gastric Bypass for Morbid Obesity

Background: Women who suffer from morbid obesity are often infertile. If these women are able to become pregnant, they are considered high risk because of the hypertension, diabetes and other associated risk factors. Following the pregnancy is difficult due to limitations of the physical examinations. More costly ultrasound examinations are needed at a higher frequency. Bariatric surgery reduces the woman's weight and the incidence of obesity related co-morbidities. The number of pregnancies and rate of complications during those pregnancies in our post-bariatirc surgical patients were evaluated. Method: Our group has been doing bariatric surgery since the early 1980s. We have over 2000 active patients on our current newsletter mailing list. The patients also have a series of networks through support groups. The patients are informed to contact us when they become pregnant so we may assist the obstetrician with their care. Through these various means, we have been able to identify 41 women in our patient population who have become pregnant. Using personal interview, questionnaire, and review of perinatal records, pregnancy-related risks and complications were studied. Results: With over a 95% follow-up rate on the patients identified as having been pregnant following surgery, we found less risk of gestational diabetes, macrosomia, and cesarean section than associated with obesity. There were no patients with clinically significant anemia. Conclusion: Since the patients had an operation that restricts their food intake, some basic precautions should be taken when they become pregnant. With this in mind, our patients have done well with their pregnancies. The post-surgical group had fewer pregnancy-related complications than did an internally controlled group that were morbidly obese during their previous pregnancies.     

A Prospective Randomized Study Comparing Patients with Morbid Obesity Submitted to Laparotomic Gastric Bypass with or without Omentectomy

Background  Visceral fat, especially the greater omentum, seems to be an important factor in the development of some metabolic disturbances such as insulin resistance, hyperglycemia, and dyslipidemia. Therefore, we wanted to evaluate the influence of resecting or leaving in situ the greater omentum in a group of patients with morbid obesity. Methods  Seventy patients with morbid obesity were submitted to laparotomic resectional gastric bypass and an omentectomy was randomly performed in some patients. Body mass index (BMI), serum levels of sugar, insulin, total cholesterol, and triglycerides were determined prior to surgery and followed up on for 2 years afterwards. Results  Two years after surgery, no differences were seen in BMI levels in either group. Blood sugar levels, serum insulin, total cholesterol levels, and serum triglycerides had similar values in both groups. Arterial hypertension had similar behavior. Conclusions  Based on these results, omentectomy is not justified as part of bariatric surgery. Its theoretical advantages are not reflected in this prospective random trial.     

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).     

Anastomotic Leak following Antecolic versus Retrocolic Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Laparoscopic Roux-en-Y gastric bypass(LRYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States. Previous reports suggest that postoperative complications may be influenced by Roux limb orientation (antecolic versus retrocolic), although thisremains controversial. The aim of this study was toanalyze our experience with anastomotic leaks following LRYGBP with an antecolic- versus retrocolicrouted Roux limb. Methods During the 2-year period of June 2003 to June 2005, 353 patients underwent a LRYGBP. 135 were antecolic and 218 retrocolic. All cases were performedby one of three bariatric surgeons. The decisionto perform antecolic versus retrocolic LRYGBP was left to the surgeon’s preference. The primary outcome measure was anastomotic leak. Results Mean follow-up was 28 weeks. There wereno perioperative deaths. Overall complication rate was 16.9%. 17 gastrojejunal leaks (4.8%) were identified, consisting of 12 intraoperative leaks (3.4%) and 5 postoperative leaks (1.4%). Postoperative gastrojejunal leak rate was higher in the antecolic group (P = 0.04). Conclusion Mortality and complication rates were consistent with reported benchmarks on the efficacy and safety of LRYGBP. Our review suggests that anastomotic leak may be more common after antecolic than after retrocolic LRYGBP for morbid obesity. A prospective randomized study is needed to determine whether antecolically-routed Roux limb is an independent predictor for anastomotic leak following LRYGBP.     

Failure of Mesenteric Defect Closure After Roux-en-Y Gastric Bypass

Background and Objectives:

Bowel obstructions following Roux-en-Y gastric bypass (RYGB) are a significant issue often caused by internal herniation. Controversy continues as to whether mesenteric defect closure is necessary to decrease the incidence of internal hernias after RYGB. Our purpose was to evaluate the effectiveness of closing the mesenteric defect at the jejunojejunostomy in patients who underwent RYGB by examining this potential space at reoperation for any reason.

Methods:

We retrospectively reviewed medical records of patients undergoing surgery after RYGB from August 1999 to October 2008 to determine the status of the mesentery at the jejunojejunostomy.

Results:

Eighteen patients underwent surgery 2 to 19 months after open (n=8) or laparoscopic (n=10) RYGB. All patients had documented suture closure of their jejunojejunostomy at the time of RYGB. Permanent (n=12) or absorbable (n=6) sutures were used for closures. Patients lost 23.6kg to 62.1kg before a reoperation was required for a ventral hernia (n=8), cholecystectomy (n=4), abdominal pain (n=4), or small bowel obstruction (n=2). Fifteen of the 18 patients had open mesenteric defects at the jejunojejunostomy despite previous closure; none were the cause for reoperation.

Conclusion:

Routine suture closure of mesenteric defects after RYGB may not be an effective permanent closure likely due to the extensive fat loss and weight loss within the mesentery.     

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.     

Gastric Bypass for Morbid Obesity: a Standard Surgical Technique by Consensus

Background: The gastric bypass operation has evolved since 1966 when it was first introduced. The purpose of this study was to determine the present state of gastric bypass by consensus among the members of the American Society for Bariatric Surgery (ASBS). Method: A questionnaire was sent to all members of the ASBS. Forty-three percent responded reporting over 41,200 cases. Results: Results were analyzed by using χ² tests with a null hypothesis. Surgeons agreed on several technical aspects, preferring a vertical to a horizontal stapleline; estimating, rather than measuring, the pouch volume at an average of 22 cc. Few surgeons divide the short gastric vessels, and only 25% of surgeons polled use a restrictive ring or band proximal to the gastroenterostomy. Most surgeons calibrate the gastroenterostomy, reporting a preferred average diameter of 12.3 cm. There was no consensus regarding forming the gastroenterostomy, 58% preferring hand-sewn and 42% stapled anastomoses. There was no consensus regarding dividing the gastric pouch from the bypassed stomach: Conclusion: The preferred gastric bypass is vertical, with the pouch estimated at 20-25 cc, and the gastroenterostomy calibrated at 12 mm diameter. The short gastric vessels need not be divided, and restrictive bands or rings are not preferred. This technique of gastric bypass should be used as the control procedure when modifications are tested in future trials. Randomized prospective studies are suggested to probe the benefits of division of the stomach pouch from the bypassed stomach.     

Pregnancy Following Gastric Bypass Surgery for Morbid Obesity: Maternal and Neonatal Outcomes

Background The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery. Methods Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI). Results Despite gastric bypass, the 38 cases were heavier (BMI 33.4 ± 7.3 vs. 28.1 ± 6.7 kg/m², p < 0.001) and more often obese (BMI ≥ 30 kg/m², 26/38 (68.4%) vs. 20/76 (26.3%), p < 0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66–10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02–3.38), oligohydramnios (OR 2.39, 95% CI 0.66–8.61), and delivery ≥41 weeks (OR 0.57, 95% CI 0.11–2.97). Discussion Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population. Reprints unavailable.     

The Effect of Laparoscopic Roux-en-Y Gastric Bypass on Fibromyalgia

Background Fibromyalgia is a chronic debilitating disorder affecting 3–5% of the US population. Treatment of this disorder is a challenge. The incidental finding of improvement of fibromyalgia following laparoscopic Roux-en-Y gastric bypass stimulated us to study this phenomenon. Methods A retrospective chart review of patients with fibromyalgia who underwent laparoscopic Roux-en-Y gastric bypass. Results Postoperative decrease in median of BMI from 49.4 to 29.7 was significant (p value = 0.0010). This was associated with statistically significant improvement in median of pain score (p value = 0.0010) and median points of tenderness (p value = 0.0010). Conclusion Significant weight loss following laparoscopic Roux-en-Y gastric bypass is associated with resolution or improvement of fibromyalgia. Consequently, the bariatric surgeon should be a member of the multidisciplinary team approach for treating fibromyalgia.     

Effect of Roux-en Y Gastric Bypass on Bone Metabolism in Patients with Morbid Obesity: Mansoura Experiences

Background  Roux-en-Y gastric bypass (RYGBP) has been found to be the most efficient way to lose weight and maintain the weight loss in morbid obesity. However, with the formation of a new stomach and the modification of intestinal anatomy, there are significant changes on bone metabolism. The objectives of this study were to evaluate effects of weight loss on bone metabolism after Roux-en Y gastric bypass in patients with morbid obesity. Methods  Our study included 70 patients with morbid obesity; RYGB was done for all patients. Daily postoperative oral supplementation with 1,000 mg of calcium and 800 IU of vitamin D was done for each patient. Body weight (BW), body mass index (BMI), total body fat, total lean tissue mass, bone mineral content (BMC), bone mineral density (BMD), total bone area (TBA; using dual energy X-ray absorptiometry), serum calcium, parathyroid hormone (PTH), 25-OH vitamin D, 24-h urinary calcium, and bone-specific alkaline phosphatase (BSAP) were assessed preoperatively and 1 year after surgery. Results  In our study, females comprised 70% of cases. The mean age was 35 ± 8.8 years. One year after RYGB, BW decreased significantly from 132.8 ± 26.5 to 90.3 ± 17.3 kg (p = 0.001). BMI decreased significantly from 48 ± 7.3 to 32.6 ± 4.1 kg/m² (p = 0.001). BMC decreased significantly from 2,968.6 ± 71.4 to 2,700.8 ± 45.4 g (p = 0.001). BMD decreased significantly from 1.026 ± 0.03 to 1.22 ± 0.015 g/cm² (p = 0.001). TBA decreased significantly from 2,356.2 ± 35.4 to 2,216.3 ± 43.5 cm² (p = 0.001). Serum calcium, 24-h urinary calcium, and BSAP were not significantly decreased while 25-OH vitamin D and PTH were not significantly increased after surgery. Conclusions  From this study, it is shown that RYGBP operation gives very good results as regards reduction of body weight in morbidly obese patients. Postoperative supplementation with calcium and vitamin D partially corrects osteoporosis. Thus, these patients need periodic follow-up for BMD, PTH, calcium, serum vitamin D, and markers of bone resorption and formation specially postmenopausal female.     

Calcium Intake and Metabolic Bone Disease after Eight Years of Roux-en-Y Gastric Bypass

Background Roux-en-Y gastric bypass (RYGBP) has been found to be the most efficient way to lose weight and maintain the weight loss in morbid obesity. However, with the formation of a new stomach and the modification of intestinal anatomy, there are significant changes on physiological properties of these organs that lead to nutrient deficiency, including calcium. The objectives of this study were to evaluate calcium intake, bone metabolism, and prevalence of metabolic bone disease in women subjected to RYGBP after 8 years. Methods Food frequency questionnaire and 3-day dietary recall, laboratory tests of bone metabolism and bone mineral density were accessed. Results Calcium intake was below the recommendation in all women. Serum PTH and alkaline phosphatase were elevated, whereas vitamin D and urinary calcium were significantly lower. Also, a higher prevalence of metabolic bone disease than the one expected for the normal population at the same age was noted. Conclusion These data suggest that metabolic bone disease could be a complication of this type of surgery.     

Preoperative Weight Loss as a Predictor of Long-term Success Following Roux-en-Y Gastric Bypass

BACKGROUND: All patients undergoing gastric bypass surgery at this institution are recommended to achieve a goal of 10% total body weight (TBW) loss prior to surgery. The objective of this study was to determine whether preoperative TBW correlated with 3- and 4-year weight loss outcome. METHODS: This study was conducted prospectively at a large teaching hospital. All adult patients with 3- and 4-year follow-up data since the start of the study in 1998 to September 2007 were included. All data are expressed as mean +/- SD. Pairwise correlation and ordinary least squares regression analysis was used to determine the strength of association between preoperative TBW loss and weight loss at 3 and 4 years. RESULTS: One hundred fifty patients (120 females), age 45.3 +/- 8.9 years, were included. Their body mass indexes (BMIs), preoperatively and after 3 years, were 52.2 +/- 9.8 and 35.4 +/- 8.2 kg/m(2), respectively. There was a significant correlation between preoperative and 3-year TBW lost (9.5 +/- 6.8% vs 31.9 +/- 11.7%, r = 0.302, p = 0.0002) and between excess body weight (EBW) lost preoperatively and after 3 years (16.1 +/- 11.3% vs 55.1 +/- 20.2%, r = 0.225, p = 0.006). Ninety five patients had follow-up data available at 4 years. Their mean preoperative BMI was 52.6 +/- 9.7 kg/m(2) and decreased to 37.5 +/- 9.0 kg/m(2). The TBW loss prior to and after surgery (10.0 +/- 6.5% vs 29.4 +/- 11.5%) was significantly correlated (r = 0.247, p = 0.015). The EBW loss preoperatively and after 4 years correlated positively (17.1 +/- 11.1% vs 50.8 +/- 19.8%, r = 0.205, p = 0.046). CONCLUSION: There is a significant correlation between weight loss attained preoperatively and sustained weight loss at 3 and 4 years.     

Treatment of Morbid Obesity and Gastroesophageal Reflux with Hiatal Hernia by Lap-Band

Background: Esophageal reflux is common in obese patients. Hiatal hernia is considered a potential contraindication to placement of a Lap-Band. Methods: Esophageal investigation in patients who were candidates for a Lap-Band included clinical evaluation of symptoms (scoring system), endoscopic and radiologic evaluation, 24-h pH test, and stationary manometry. Patients with gastroesophageal reflux (GER) with or without hiatal hernia underwent the Lap-Band procedure. Results: GER was diagnosed in 12/40 morbidly obese patients, 11 of whom received a standard Lap-Band (3 patients were radiologically diagnosed with transient hiatal hernia). One patient with a large hiatal hernia underwent closure of the diaphragmatic esophageal hiatus, and the Lap-Band was positioned similarly to an Angelchik prosthesis. All but 1 patient who was lost at follow-up were symptom-free (range 1-24 months). Conclusion: GER with or without hiatal hernia is not a contraindication for obese patients undergoing a Lap-Band procedure. It accomplishes by a single operation satisfactory treatment of these two disturbing diseases.     

Symptomatic and Clinical Improvement in Morbidly Obese Patients with Gastroesophageal Reflux Disease Following Roux-en-Y Gastric Bypass

Background: Patients who suffer with gastroesophageal reflux Disease (GERD) endure a worsening of symptoms as their weight increases. When medical treatment of this condition in the morbidly obese patients fails, surgical intervention may be indicated. Choosing a procedure which not only helps achieve weight control but which also relieves symptoms and complications of GERD is the goal. We present a review of patients who have undergone Roux-en-Y Gastric Bypass (RYGBP) and related procedures for this disease. Methods: One hundred eighty-eight patients undergoing surgery for morbid obesity and for GERD in 1992-1996 were contacted by mail or phone. All of these patients had undergone preoperative esophagogastroduodenoscopy to grade the severity of their disease. Their preoperative symptoms were compared to those experienced postoperatively. Results: One hundred thirty patients underwent a RYGBP with modified Hill fundopexy, 22 patients underwent a distal gastrectomy with modified Hill fundopexy, 8 patients underwent distal gastrectomy alone and 28 patients underwent RYGBP alone. There have been no deaths. There were nine surgical complications, eight early and one at 2.5 years postoperation. Follow-up is 4-48 months. The average BMI dropped from 43 to 30.2 kg/m². Whereas all patients were on some form of medical therapy before surgery, only 14 reported the need for medication postoperatively. Conclusions: Surgical intervention for weight control and treatment of GERD has been highly successful in our experience both with respect to weight control and to the reduction of reflux symptoms. Depending upon endoscopic and operative findings a RYGBP with or without an antireflux procedure can provide dramatic improvement. Gastrectomy with antireflux modifications is appropriate in selected cases.     

Intestinal Microflora Settlement in Patients with Jejunoileal Bypass for Morbid Obesity

Intestinal microflora settlement was evaluated in this retrospective study of 49 patients with jejunoileal bypass who required reoperation. Colonic microflora was observed in the samples of the contents of the functioning jejunum and ileum but not in 55% of the samples from the middle of the excluded loop. Colonization of the excluded loop was not detected in patients without clinical signs of bacterial overgrowth but was significantly frequent (p < 0.01) in those with clinical signs (bloating, migratory arthralgias, rashes, skin lesions). However, positive excluded loop cultures were not always associated with clinical manifestations. No significant correlation was observed between bacteriology of the contents of the excluded loop and bypass results. The success of an intestinal bypass may depend not only on anatomic and functional adaptation to the new, surgically created conditions, but also to the attainment of microbiological equilibrium in the intestinal ecosystem.     

Factors Affecting Morbidity and Mortality of Roux-en-Y Gastric Bypass for Clinically Severe Obesity: An Analysis of 1,000 Consecutive Open Cases by a Single Surgeon

Introduction Determinants of perioperative risk for RYGB are not well defined. Methods Retrospective analysis of comorbidities was used to evaluate predictors of perioperative risk in 1,000 consecutive patients having open RYGB by univariate analyses and logistic regression. Results One hundred forty-six men, 854 women; average age 38.3 ± 11.2 years; mean BMI 51.8 ± 10.5 (range 24–116) were evaluated. Average hospital stay (LOS) was 3.8 days; 87% <3 days. 91.3% of procedures were without major complication. The most common complications were incisional hernia 3.5%, intestinal obstruction 1.9%, and leak 1.6%. 31 patients required reoperation within 30 days (3.1%). A 30-day mortality was 1.2%. Logistic regression evaluating predictors of operative mortality correlated strongly with coronary artery disease (CAD) (p < 0.01), sleep apnea (p = 0.03), and age (p = 0.042). BMI > 50 (0.6 vs 2.3%, p = 0.03) and male sex were associated with increased mortality (1.3 vs. 4.0%, p = 0.02). Sex-specific logistic regression demonstrated males with angiographically proven CAD were more likely to die (p = 0.028) than matched cohorts. Age (p = 0.033) and sleep apnea (p = 0.040) were significant predictors of death for women. Conclusion Perioperative mortality after RYGB appears to be affected by sex, BMI, age, CAD, and sleep apnea. Strategies employing risk stratification should be developed for bariatric surgery. Presented in part at the Annual Meeting of the SSAT, Orlando, FL, May 2003     

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.     

Resolution of Diabetes Mellitus and Metabolic Syndrome following Roux-en-Y Gastric Bypass and a Variant of Biliopancreatic Diversion in Patients with Morbid Obesity

Background Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2. Methods The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1±2.9 kg/m²) and 111 BPD-RYGBP (BMI 59.7±10.6 kg/m²). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39±21.17 months. Results Excess weight loss was ∼70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose <110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups. Conclusions RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP.We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.