Roux-en-y Gastric Bypass

Background: Thyroid dysfunction is associated with obesity but little is known about the long-term changes in thyroid function caused by weight loss. The purpose of this study is to compare the metabolic profile and percentage excess weight loss (%EWL) in hypothyroid and euthyroid patients submitted to bariatric surgery. Methods: 505 patients were divided into two groups: hypothyroid (H) and euthyroid (E). They were compared regarding Body Mass Index (BMI), %EWL and metabolic profile [metabolic syndrome (MS), HOMA IR, free T4, TSH]. Results: 423 were women (83.7%); 54 subjects (10.7%) had hypothyroidism (H), of which 51(94.4%) were females. The percentage of females and males affected by hypothyroidism was 12.1% vs. 3.7%, respectively [pϭ0.04]. Mean BMI of H was 41.5Ϯ5.1kg/m 2 , and E 42.2Ϯ4.7 kg/m 2 [pϭ0.22]. Mean age of H was 39.9Ϯ10 years and E 36.8Ϯ10.3 years [pϭ0.03]. Metabolic syndrome was present in 294(58.21%) of total patients, corresponding to 57% of H and 59% of E[pϭ0.92]. Mean HOMA IR in H was 6.4Ϯ 7.8(1.49-53.35) and E 4.61Ϯ3.3(0.09-27.72)[pϭ0.16]. After 1 year %EWL was, in H, 61.4Ϯ10.2% and E,71.3Ϯ15.1%[pϭ0.0001]. After 2 years, %EWL was in H 68.9Ϯ13.7% and E 71.2Ϯ16.4%[pϭ0.18]. In H, preoperative TSH was 2.99Ϯ3.03(0.05-8.79) and, one year after surgery, 3.23Ϯ1. 94(0.01-7.04)[pϭ0.81]. In E, preoperative TSH was 2.86Ϯ1.59(0.98-9.40) and, one year after, 2.06Ϯ1. 23(0.45-7.5)[pϽ0.0001]. Mean free T4 in E before surgery was 1.01Ϯ 0.26(0.7-1.8) and, one year after, 1.09Ϯ0.15(0.7-1.4)[pϭ 0.07]. Conclusion: Women showed a higher percentage of hypothyroidism. There was no difference between groups regarding BMI, HOMA IR, percentage of affected by MS and %EWL after two years of follow-up. Thyroid function may vary in euthyroid obese patients after weight loss, which however, is clinically insignificant.

Substance abuse treatment patients with bariatric surgery histories were recruited to participate in a study examining the onset of substance abuse relative to the timing of their bariatric surgery. Participants completed a questionnaire packet and a semistructured interview. Data collection is ongoing. To date, the sample primarily consists of White (88.2) women (77.8%) with a mean age (Ϯ SD) of 43.83(Ϯ 10.5), mean BMI (Ϯ SD)of 31.85(Ϯ 7.20) kg/m 2 , and mean post-surgical weight loss (Ϯ SD) of 120.83(Ϯ 56.25) pounds. Qualitative interview data (Nϭ20) were used to evaluate participants' perceptions of the etiology of their substance abuse problems and their recommendations for treatment providers working with bariatric patients. Results: Four themes emerged regarding substance abuse etiology, namely unresolved psychological problems (i.e., pre-existing but unresolved problems and identity shifts associated with dramatic weight loss), addiction substitution, faster substance metabolism with more intense effects, and increased availability of pain medications. Three themes for future recommendations emerged including counseling pre-and post-surgery, increasing education/ knowledge regarding associated risks of substance abuse postsurgery, and "honesty" on behalf of both patients and staff during the pre-surgical evaluation. Representative quotes will be presented for each theme. In addition, representative trajectories of substance abuse development relative to bariatric surgery will be depicted. Implications include increased psychological treatment pre-and post-surgery, with a particular focus on navigating identity shifts, and increased education related to substance abuse risks.

Background: Concerned about the growing shortage of health professionals in our area and nationwide, we developed a program for high school students to increase interest in healthcare careers. We built on our traditional use of live broadcast surgery to teach medical students about surgery. Our new initiative, "Surgery Live!" was developed in collaboration with Highmark Blue Shield and the Whitaker Center for Science and the Arts. Methods: A multi-disciplinary team collaborated on all aspects of the program, including pre-visit teaching modules. Laparoscopic gastric bypass was chosen as a frequently performed elective procedure with high definition video images, and because a variety of health professionals are involved in these patients' care. An educational grant from Highmark Blue Shield provided for an independent research firm to evaluate our program through follow-up questionnaires. Results: Our six "Surgery Live!" sessions had 421 students during the 2008-2009 academic year. A total of 226 student surveys were returned (63%). Two-thirds of responders agreed they had considered a career in health care prior to attending the session. Of these students, the largest group (47%) reported higher interest after attending (pϽ0.05). Of the 14% who had not considered a health care career, 17% reported higher interest following our session. Only two percent of all students reported lower interest in health care careers after attending "Surgery Live!" Conclusion: Live broadcast surgery provides a unique format to encourage students to pursue healthcare careers, and increases interest for those already open to them. Presenting bariatric procedures involves the added benefit of educating students about the treatment of obesity.

Background: This study illustrates our experience in laparoscopic Roux-en-Y gastric bypass (LRYGBP) using a new technique for creating the gastrojejunostomy. Methods: Between April and November 1999, 28 patients underwent LRYGBP. In the first 10 patients the transoral route with endoscopic guidance was utilized for placement of the anvil in the gastric pouch. A new totally intra-peritoneal approach was utilized in the next 18 patients, avoiding the transoral route. Results: There were 23 women and 5 men with an average age of 36 years (range 24-51). The mean BMI was 47, with range 41-64. Of the patients, 82% had one or more associated co-morbid conditions (hypertension, diabetes, sleep apnea, arthritis). Average operative time in the first 10 patients using the trans-oral route with endoscopic guidance was 340 minutes (range 240-390 min). The next 18 patients underwent totally intra-peritoneal anvil placement with a 240-minute average operating time (range 150-310 min). There were no open conversions or mortalities. There were 4 complications, including 2 wound infections, one urinary tract infection, and one intra-abdominal abscess. The two wound infections occurred in the first 10 patients that underwent trans-oral introduction of the anvil. Conclusions: LRYGBP was a safe and feasible operation. We believe that our technique is easily reproducible, avoiding the trans-oral route for introducing the anvil. This technique may also decrease operative time and possibly the incidence of wound infections, although we are still in the learning curve and final conclusions cannot be made.

Background: Roux-en-Y gastric bypass (RYGB) surgery is an effective treatment for morbid obesity and its comorbid medical conditions. RYGB can lead to nutritional and metabolic deficiencies related to decreased oral intake and micronutrient malabsorption. Vitamin D deficiency in the morbidly obese coupled with decreased calcium absorption following surgery may lead to osteomalacia and osteoporosis after RYGB. The aim of this study is to evaluate changes in bone mineral density (BMD) and body composition following RYGB. Methods: Twenty white females who underwent RYGB surgery were assessed pre-and postoperatively with nutritional measurements and dual-energy x-ray absorptiometry (DXA). Results: The participants were 45Ϯ10 years of age and underwent RYGB surgery 792 Ϯ110 days prior to postoperative DXA imaging. Average lumbar t-score (0.35 unit decrease), neck t-score (0.71 unit decrease), neck z-score (0.60 unit decrease), body weight (30% decrease), bone mineral content (10% decrease), fat mass (40% decrease), lean body mass (18% decrease), and percent body fat (17% decrease) significantly decreased following surgery (p-valuesϽ0.0001). The percent of neck t-scores in the osteopenic range (pre 15% pre vs post 35%, pϭ0.046) and total body t-scores in the osteopenic range (pre 5% vs post 25%, pϭ0.046) increased following surgery. Conclusion: After RYGB, women in this study lost not only significant fat mass as expected, but also significant bone mineral content and lean body mass. The change in bone mineral content may account for the increased rate of postoperative osteopenia though other factors such as age and menopausal status may play a role.

Hypothesis: Modest, preoperative weight loss will improve perioperative outcomes among high-risk, morbidly obese patients undergoing Roux-en-Y gastric bypass. Design: A prospective, longitudinal assessment of characteristics and outcomes of gastric bypass patients. All patients undergoing open or laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity or its comorbid medical problems at Geisinger Medical Center in Danville, Pennsylvania, during a 3-year period from May 31, 2002, to February 24, 2006, were included in this analysis. Patients were required to participate in a standardized multidisciplinary preoperative program that encompasses medical, psychological, nutritional, and surgical interventions and education. In addition, patients were encouraged to achieve a 10% loss of excess body weight prior to surgical intervention. Results: Of the 884 subjects, 425 (48%) lost more than 10% of their excess body weight prior to the operation. After surgery (mean follow-up, 12 months), this group was more likely to achieve 70% loss of excess body weight (P Ͻ.001). Those who lost more than 5% of excess body weight prior to surgery were statistically less likely to have a length of stay of greater than 4 days (P=.03). This study shows that high-risk morbidly obese candidates for bariatric surgery who are able to achieve a loss of 5% to 10% excess body weight prior to surgery have a higher probability of a shorter length of hospital stay and more rapid postoperative weight loss.

The gastrointestinal (GI) tract can play a direct role in glucose homeostasis by modulating the digestion and absorption of carbohydrates and by producing the incretin hormones. In recent years, numerous studies have focused on intestinal adaptation following bariatric surgeries. Changes in the number of incretin-(GLP-1, GIP) producing cells have been reported which could result in the modified hormonal response seen after surgery. Additionally, the rate of absorption and the intestinal regions exposed to sugars may affect the time course of appearance of glucose in the blood. This reviewgives new insightsinto the direct role of the GI tract in the metabolic outcomes of bariatric surgery,in the context of glucose homeostasis.

Roux‐en‐y gastric bypass (RYGB) surgery is associated with dramatic improvements in obesity‐related comorbidity, but also with nutritional deficiencies. Vitamin D concentrations are depressed in the severely obese, but the impact of weight loss via RYGB is unknown. We determined associations between adiposity and systemic 25‐hydroxyvitamin D (25(OH)D) during weight loss and the immediate and longer‐term effects of RYGB. Plasma 25(OH)D concentrations and fat mass (FAT) were determined by immunoassay and air displacement plethysmography, respectively, at 0 (before RYGB surgery), and at 1, 6, and 24 months in severely obese white and African American (AA) women (n = 20). Decreases in adiposity were observed at 1, 6, and 24 months following RYGB (P < 0.05). Plasma 25(OH)D concentrations increased at 1 month (P = 0.004); a decreasing trend occurred over the remainder months after surgery (P = 0.02). Despite temporary improvement in vitamin D status, a high prevalence of vitamin D insu...

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce lessthan-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a "liver suspension tape" that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P<0.001). Patients treated with the fiveport method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P=0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P=0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.

Background: The authors reviewed the benefits of routine placement of closed drains in the peritoneal cavity following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of the study was to determine whether routine closed abdominal drainage provides diagnostic and therapeutic advantages in the presence of complications such as bleeding and leaks. Materials and Methods: The medical records of 593 consecutive patients who had undergone LRYGBP from July 2001 through May 2003 were retrospectively reviewed. In all cases, antecolic antegastric LRYGBP was performed. Two 19-Fr Blake closed suction drains were left in place, one at the gastrojejunostomy and the other at the jejunojejunostomy. The incidence of bleeding and leaks was reviewed, and the utility of the drains relative to diagnosis and management was evaluated. Results: Bleeding presented in 24 patients (4.4%); in 8, the diagnosis was based on increased sanguinous output from the drain and decreased hematocrit. None of the patients with intraabdominal bleeding required reoperation. Of the 10 patients (1.68%) who presented with leaks, the diagnosis was made within 48 hours postoperatively in 5 patients (50%), based on the characteristics of the drain output. Nonoperative management with drainage and total parenteral nutrition was accomplished in 5 (50%) of the 10 patients with leaks. There was no mortality in the series. Conclusion: The routine use of abdominal drains after LRYGBP appears to be beneficial. Drains allowed early diagnosis of complications and in most cases, the successful treatment of leaks. When bleeding is suspected or documented, appropriate volume replacement therapy is mandatory to maintain adequate hemodynamic parameters. Drain output may orient the surgeon to take preventive measures such as discontinuing anticoagulation and early fluid resuscitation. In this series, in most cases the bleeding spontaneously stopped and no further surgical management was required.

Dumping syndrome is a frequent complication of cancer and non-cancer oesophageal and gastric surgery, as well as bariatric surgery (also known as metabolic surgery). These interventions change gastric anatomy and innervation, which can enable a considerable amount of undigested food to reach the small intestine too rapidly 1-4. Dumping syndrome comprises a constellation of symptoms that can be subdivided into early and late dumping syndrome symptoms, which can occur jointly or separately 1-8. Typically, symptoms of early dumping syndrome occur within the first hour after a meal and include gastrointestinal symptoms (abdominal pain, bloating, borborygmi, nausea and diarrhoea) and vasomotor symptoms (flushing, palpitations, perspiration, tachycardia, hypotension, fatigue, desire to lie down and, rarely, syncope) 1,2. The underlying mechanisms might involve osmotic effects, peptide hormone release and autonomic neural responses 1. Symptoms of late dumping syndrome usually occur between 1 and 3 h after a meal and are primarily the manifestations of hypoglycaemia, which mainly results from an incretin-driven hyperinsulinaemic response after carbohydrate ingestion. Hypoglycaemia-related symptoms are attributable to neuroglycopenia (which is indicated by fatigue, weakness, confusion, hunger and syncope) and to vagal and sympathetic activation (indicated by perspiration, palpitations, tremor and irritability) 1,2. The literature has referred to late dumping syndrome as 'reactive hypoglycaemia' or, after bariatric surgery, as 'postbariatric hypoglycaemia'. However, on the basis of a common pathophysiology of rapid exposure of the small intestine to nutrients, which is also seen in early dumping syndrome (see subsequent discussion), we refer to this phenomenon as 'late dumping syndrome'. The prevalence of dumping syndrome depends on the type and extent of surgery, and on the criteria used to diagnose dumping syndrome. Dumping syndrome occurs in approximately 20% of patients undergoing

Background: Bariatric surgery is the treatment of choice for morbid obesity. Since bariatric operations alter gastrointestinal anatomy, they may induce symptoms that have a negative impact on quality of life (QOL). The aim of this study was to prospectively analyze QOL after bariatric surgery. Methods: The QOL index questionnaire (GIQLI) was applied to 45 surgically treated morbidly obese patients (15 vertical banded gastroplasty, 15 Rouxen-Y gastric bypass (RYGBP), and 15 distal RYGBP) and to 15 non-operated morbidly obese controls. Follow-up was of 1-year minimum. The GIQLI evaluates physical and mental well-being, digestion and bowel habits. Results: Physical and mental well-being as well as the overall QOL were significantly higher in the operated patients. There were no significant differences in digestion and bowel habits between the groups. Differences in QOL were not related to the type of surgical procedure. Conclusion. Overall QOL was significantly better in operated than in non-operated patients. There is no negative impact of bariatric surgery on QOL related to GI symptoms.

Hypothesis: Circulating ghrelin, produced primarily in the stomach, is a powerful orexigen. Ghrelin levels are elevated in states of hunger, but rapidly decline postprandially. Early alterations in ghrelin levels in morbidly obese patients undergoing weight reduction surgery may be attributed to gastric partitioning. Design and Patients: Thirty-four patients underwent Roux-en-Y gastric bypass with a completely divided gastroplasty to create a 15-mL vertically oriented gastric pouch. Eight other patients underwent other gastric procedures that did not involve complete division of the stomach, including 4 vertical banded gastroplasties and 4 antireflux surgical procedures. Six additional patients undergoing antireflux surgery served as lean control subjects. Plasma samples were obtained before surgery and immediately after surgery. In a substudy, plasma was collected after Rouxen-Y limb formation and after dividing the stomach to identify any changes in plasma ghrelin levels. Setting: Tertiary university medical center. Main Outcome Measures: Ghrelin levels at different stages of surgical intervention.

Glycemic disorders resolve following Roux-en-Y gastric bypass (RYGB) surgery, but early and longer-term mechanisms regarding effects on β-cell dysfunction as well as relationships with decreasing adiposity are not well understood. We evaluated longitudinal changes in peripheral insulin sensitivity (Si), the acute insulin response to glucose (AIRg), and the composite estimate of β-cell function, the disposition index (DI), over 24 mo via frequently sampled intravenous glucose tolerance testing in severely obese women who had fasting normoglycemia ( n = 16) and hyperglycemia ( n = 11) before RYGB surgery; homeostatic model assessment (HOMA-IR) estimated insulin resistance; air displacement plethysmography determined adipose tissue mass. At baseline, subjects with normoglycemia had adequate DI associated with elevated AIRg, but DI was markedly reduced in subjects with hyperglycemia. Within 1–6 mo post-RYGB, glycemic control was normalized in subjects with hyperglycemia related to reduc...

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Background Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) represent two of the most used bariatric/ metabolic surgery (BMS) procedures. Gut microbiota (GM) shift after bypass surgeries, currently understated, may be a possible key driver for the short-and long-term outcomes. Methods Prospective, multicenter study enrolling patients with severe obesity, randomized between OAGB or RYGB. Fecal and blood samples were collected, pre-(T0) and 24 months postoperatively (T1). GM was determined by V3-V4 16S rRNA regions sequencing and home-made bioinformatic pipeline based on Qiime2 plugin and R packages. Objects To compare OAGB vs RYGB microbiota profile at T1 and its impact on metabolic and nutritional status. Results 54 patients completed the study, 27 for each procedure. An overall significant variation was detected in anthropometric and serum nutritional parameters at T1, with a significant, similar decrease in overall microbial alpha and beta diversity observed in both groups. An increase in relative abundances of Actinobacteria and Proteobacteria and a reduction of Bacteroidetes, no significant changes in Firmicutes and Verrucomicrobia, with an increase of the Firmicutes/Bacteroidetes ratio were observed. Conclusions BMS promotes a dramatic change in GM composition. This is the first multicenter, RCT evaluating the impact of OAGB vs Roux-en-Y bypass on GM profile. The bypass technique per se did not impact differently on GM or other examined metabolic parameters. The emergence of slightly different GM profile postoperatively may be related to clinical conditions or may influence medium or long-term outcomes and as such GM profile may represent a biomarker for bariatric surgery's outcomes.

The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases yet standard ERCP is not possible due to surgically altered gastroduodenal anatomy. Laparoscopic-ERCP (LA-ERCP) has been proposed as an option but supporting data are derived from single center small case-series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. This is retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all of the following were achieved: reaching the papilla, cannulating the desired duct and providing endoscopic therapy as clinically indicated. A total of 579 patients (median age 51, 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Proc...

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG), have been proposed as cost-effective strategies to manage obesity-related chronic disease. The objectives of this meta-analysis and systematic review were to analyze the &quot;late postoperative complication rate (&gt;30 days)&quot; for these 2 procedures. Randomized controlled trials (RCTs) published between 2000 and 2015 comparing the late complication rates, that is, &gt;30 days following LVSG and LRYGB in adult population (ie, 16 y and above) were selected from PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane database. The outcome variables analyzed included mortality rate, major and minor complications, and interventions required for their management and readmission rates. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity among the outcome variables of these trials was determined by the C...

The objective of the present study was to identify the factors which contribute to the appearance and/or aggravation of Vitamin A Deficiency (VAD) in individuals with morbid obesity in the preand postoperative stages of Roux-en-Y gastric bypass (RYGBP). Bibliography searches were done in the databases of Medline and Lilacs, published in the last 35 years, priorizing the studies which assessed VAD through serum levels of retinol. The principal factors identified as contributors to VAD were oxidative stress, deficiency of other nutrients, lipid malabsorption in the postoperative stage, insufficient intake of lipids and food sources of Vitamin A, and presence of nonalcoholic fatty liver disease. The investigation of the nutritional status of Vitamin A in those individuals may foment intervention strategies easily incorporated in already established routine procedures, aiming to reduce VAD rates, which will reflect upon those individuals' quality of life.

The use of barbed sutures for constructing an anastomosis is favoured by a few bariatric surgeons as compared to conventional sutures. The aim of this study is to assess safety and efficacy of barbed sutures to close the gastric pouch-jejunal anastomosis (GPJA) in laparoscopic gastric bypass (Roux-en-Y gastric bypass-RYGB, and One-Anastomosis gastric bypass-OAGB) using propensity score-matching (PSM) analysis. A retrospective analysis of patients who underwent primary laparoscopic gastric bypasses between January 2012 and December 2017 was performed. Patients were divided into two different groups (RYGB-G and OAGB-G). PSM analysis was performed to minimize patient selection bias between the two types of sutures (barbed-BS and conventional-CS) in each group. A total of 808 patients were reviewed. After PSM, 488 (244 BS vs 244 CS) patients in RYGB-G and 48 in OAGB-G (24 BS vs 24 CS) patients were compared. Median operative time was significantly shorter (p < 0.001) for BS in RYGB-G. In OAGB-G, BS were associated with a shorter operative time, although no significant difference was observed (p = 0.183). Post-operative hospital stay was significantly shorter for BS in both the groups (p < 0.001). Post-operative 30th-day complications were comparable: no leakage or bleeding of GPJA was observed in BS groups. At median follow-up of 28.78 months, no late complications were observed. Barbed sutures appear to be effective to close GPJA during gastric bypass and as safe as conventional suture. Further studies are necessary to draw definitive conclusions.

There were not differences with respect to the duration of the endoscopy, the need of a second exploration, transfusion requirements, or length of stay. Conclusion: the intravenous erythromycin is comparable to the nasogastric lavage to improve the visual quality of the urgent endoscopy in patients with UGB.

Background: Laparoscopic Roux-en-Y gastric bypass is being undertaken with increasing frequency. We describe a technique for introducing the anvil of the circular stapler using a totally transabdominal approach. Methods: One hundred consecutive patients underwent laparoscopic Roux-en-Y gastric bypass in a university-affiliated teaching hospital. Results: The cardiojejunostomy was constructed in all 100 patients using the circular stapler with no complications. No anastomotic leaks were detected postoperatively. Conclusions: The totally transabdominal approach for introducing the anvil of the circular stapler into the gastric pouch is safe and feasible.

Background: Prosthetic devices have been used in bariatric operations to control the outlet of the gastric pouch and thus maintain weight loss. A complication of these prostheses is erosion or migration into the gastric lumen. The transected banded vertical gastric bypass (TBVGBP) is one of the modifications of gastric bypass. This modification has a silastic ring placed around the pouch to form the stoma. Method: The records of patients with band erosion (BE) after this operation were reviewed, to determine the incidence, etiology, management and outcome during a 9-year period. Results: From May 1992 through May 2001, 2,949 primary and secondary TBVGBP were performed through the Center for Surgical Treatment of Obesity, utilizing 3 hospitals. 48 patients (1.63%) were documented to have BE: 40 documented by us and 8 by subsequent treating surgeons or at other facilities. Presenting symptoms were weight regain (18), stenosis or obstruction (17), pain (9), bleeding (7), and 5 were incidental findings. Some patients presented with more than one symptom. 8 were treated expectantly with spontaneous extrusion of the band. 16 bands have been removed endoscopically in 14 patients. 26 patients had open surgical revision, with 12 having band removal only and 14 band removal and revision of either the gastroenterostomy with or without band replacement or conversion to a distal Roux-en-Y gastric bypass (DRYGBP). Two patients who had revision to DRYGBP were re-revised to a longer common limb because of protein malnutrition. Three patients who had revision of the gastroenterostomy with band removal and replacement developed leaks that were managed non-surgically. Two of these re-eroded and the band was removed endoscopically with a subsequent revision to a DRYGBP. There was no death due to BE. Conclusion: BE is an uncommon complication of TBVGBP. Infection, previous bariatric operations and surgical technique play a role in BE. BE is best managed by endoscopic removal but can be treated expectantly or by open surgical intervention. Band removal without replacement or revision to DRYGBP may result in weight regain.

The advent of laparoscopic adjustable gastric banding (LAGB) during the latter part of the 20th century represents a watershed in the management of chronic obesity. In this paper we provide an overview of LAGB with respect to its development, clinical outcomes, and future role. We also address current controversies, including a comparison of LAGB with Roux-en-Y gastric bypass (RYGBP). At present LAGB seems to be increasing in popularity in the United States, whereas in Europe there seems to be a trend away from gastric banding toward RYGBP. Optimal outcomes after LAGB are a function of correct laparoscopic technique, an experienced surgical team, a well-engineered device, and intensive long-term follow-up. The majority of studies show that LAGB is an extremely safe and effective procedure, with an operative mortality of 0-0.1% and excess weight loss (%EWL) of 50-60%. Commensurate with this degree of weight loss, almost all studies show substantial improvements in obesity-related co-morbidities, such as hypertension, type II diabetes, and dyslipidemia. In addition, LAGB has been shown to be both safe and effective in the super-obese, in adolescents, and in older patients and can be delivered as an ambulatory procedure. Operative mortality and early complication rates are significantly higher for RYGBP and, whilst gastric bypass results in greater weight loss than LAGB in the first 2 years, at 3 years and beyond the difference appears to be less marked. Overall, LAGB provides a safe, effective intervention for obese patients and remains our first-choice procedure for bariatric surgery.

Introduction Internal hernias continue to be a significant source of morbidity after LRYGB. Literature addressing the technique of Roux limb construction as a predisposing factor is sparse. The objective of this study is to evaluate the impact of Roux limb construction technique on the development of internal hernias. Methods In this study, we included 444 (367 (82.7%) were females and 77 (17.3%) were males, two deaths excluded from the analysis) consecutive patients from our institutional bariatric database who underwent LRYGB. Variables collected include demographics, body mass index (BMI) before and after the procedure, and postoperative small bowel obstruction secondary to internal herniation. Technical details collected include: type of Roux-en-Y limb construction, Peterson's defect closure at initial operation, and reoperative findings. Roux limbs were constructed in 291 patients by a clockwise rotation of the bowel and jejunojejunostomy performed on the right side of the axis of the mesentery (group 1). In 151 patients, the Roux limb was constructed by a counterclockwise rotation of the Roux limb resulting in the jejunojejunostomy on the left side of the axis of the mesentery (group 2). We also analyzed the impact of Peterson's space closure on internal hernias. Fisher's exact test and Chisquare test were used for the analysis. Results Of a total 442 (mean age, 43.7±10.3 years; mean BMI pre-op was 46.4±5.1; and BMI after median follow-up of 12 months was 34.5±6.98) patients included in the study, 21 (4.7%) internal hernias were identified. Of 21 internal hernias, 17 (81%) were through Peterson's space and four (19%) were through the mesenteric defect. Group 1 patients had significantly higher overall internal hernias (20/291, 6.9% vs. 1/151, 0.7%; P=0.0018) and Peterson's hernias (16/291, 5.5% vs. 1/151, 0.7%; P=0.0089) compared with group 2. In addition, no significant difference was noted in the incidence of Peterson's hernia whether the defect was closed or not closed (closed group, 4/117 and 3.4% vs. not closed, 13/325, 4%; P=1.00). Within the group where Peterson's defect was closed, clockwise rotation and anastomosis on the right side of the axis of the mesentery was associated with significantly higher incidence of Peterson's hernias compared with counterclockwise rotation (4/54 vs. 0/ 63; P=0.043). In the group where Peterson's defect was not closed, clockwise rotation was associated with higher incidence of internal hernias that did not reach statistical significance (12/237, 5.1% vs. 1/88, 1.1%; P=0.12). Summary This study demonstrates that the technique for construction of the Roux limb is a major factor in the development of internal hernias. Construction of the Roux limb with a counterclockwise rotation of the bowel, such that both jejunojejunostomy anastomosis and ligament of Treitz are to the left of the axis of the mesentery significantly reduces the incidence of internal hernias.

major complication (1/75, 1.3%): 1 case where the strings on the device broke. There were no leaks at the GJ and no re-operations. There were no wound infections noted at the stapler introduction site. Conclusion: There is a significant learning curve associated with using the 25mm OrVil™ Device. During the 1st 25 procedures the major complication rate was 20% compared to 1.3% in the subsequent 75 cases(p ϭ 0.003). Intra-operative complications during the learning curve were not associated with post-operative complications. Surgeon experience may be a variable in this finding. The trans-oral approach does not increase the risk of wound infections.

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Background Even though internal hernia (IH) after a laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-known entity for bariatric surgeons and radiologists, accurate diagnosis remains difficult. The aim of this study was to evaluate the sensitivity and specificity of ten different CT findings in patients with a proven internal hernia after a LRYGB. Methods A retrospective analysis of all LRYGB patients who underwent an explorative laparoscopy for abdominal pain has been performed. Preoperative CT scans were individually reviewed by two radiologists specialized in abdominal CT imaging in a randomized blind way. These results were compared with the operative reports. Results Between 2004 and 2013, 7,328 patients underwent a LRYGB. One hundred sixty nine of these patients underwent an explorative laparoscopy for abdominal pain after a LRYGB, 131 of which had a preoperative CT scan. Of these 131 patients, 72 suffered from an IH. Fifty-nine patients had no IH and served as control group. Mesenteric swirl was the best predictor with for reader 1 a sensitivity of 68 % and specificity of 86 % and for reader 2 a sensitivity of 89 % and specificity of 63 %. Other signs had an even larger interobserver variability. Conclusions A CT scan can help in confirming the diagnosis of an IH, especially if a mesenteric swirl is present. However, since the presented sensitivities are variable and do not reach 100 %, IH might be missed, implicating that a high index of suspicion with a low threshold for explorative laparoscopy/tomy remains the cornerstone of appropriate treatment.

Gastrointestinal dysbiosis is common among persons with type 1 diabetes (T1D), but its potential impact on diabetic nephropathy (DN) remains obscure. We examined whether faecal biomarkers, previously associated with low-grade gastrointestinal inflammation, differ between healthy controls and T1D subjects with and without DN. Faecal samples were analyzed for levels of calprotectin, intestinal alkaline phosphatase (IAP), short-chain fatty acids (SCFA) and immunoglobulins in subjects with T1D (n = 159) and healthy controls (NDC; n = 50). The subjects with T1D were stratified based on albuminuria: normoalbuminuria (&lt; 30 mg/g; n = 49), microalbuminuria (30–299 mg/g; n = 50) and macroalbuminuria (≥ 300 mg/g; n = 60). aecal calprotectin, IAP and immunoglobulin levels did not differ between the T1D albuminuria groups. However, when subjects were stratified based on faecal calprotectin cut-off level (50 µg/g), macroalbuminuric T1D subjects exceeded the threshold more frequently than NDC (...

Background: Morbid obesity is associated with non-alcoholic fatty liver disease(NAFLD), which may progress to cirrhosis in up to 25% of patients. Pre-operative liver function tests(LFTs), abdominal ultrasonography(US), and intra-operative assessments(IA) have been proposed to evaluate for NAFLD. We sought to determine the prevalence of NAFLD in patients undergoing roux-en-y gastric bypass(RYGB) and compare the liver histology to the LFTs, US, and IA to determine if a correlation exists. Methods: Patients undergoing RYGB were retrospectively reviewed in our database from January, 2000 to September, 2007. LFTs, US, and IA were compared to liver pathology classified according to the National Institute of Diabetes & Digestive & Kidney Diseases(NIDDK) and National Institute of Health (NIH) guidelines. The student's t-and Chi-square tests were used to compare continuous and categorical variables, respectively. Results: 251 patients(38 men and 213 women with median age and BMI of 43.4+/-11.1 and 47.9+/-7.8 respectively) had routine liver biopsies performed during RYGB. Histology suggested 3% normal, 24% <5%steatosis, and 73% NAFLD. NASH(-NAFLD activity score > or = 5) was present in 18% while fibrosis was present in 34%. NAFLD was equal amongst gender(82% men vs 71% women) and more prevalent in patients > or = 45 years compared to those <45 years(83% vs 65%;p=0.0005). 83% of IA suggesting fatty liver had evidence of NAFLD(p=0.001). 246 patients had LFTs while 112 had ultrasounds. LFTs were elevated in 25.6% with AST/ALT>1 in 23.6%, which did not correlate with predicting NAFLD. 89% of those with NASH correlated with AST/ALT<1(p=0.035). US detected fatty liver in 48.2%. 58% of patients with fatty liver on US had a diagnosis of NAFLD(p<0.001). Conclusion: NAFLD is prevalent among morbidly obese patients, especially those > or = 45 years undergoing RYGB. US and IA are good predictors of NAFLD as compared to pre-operative LFTs and AST/ALT ratio. NASH is associated with an AST/ALT<1.

OBJECTIVE: This study aimed to investigate the relationship between meal frequency, the occurrence of vomiting and weight loss among patients submitted to Roux-en-Y gastric bypass up to 9 months after surgery. METHODS: Female patients (n = 80) were followed at 3-month intervals for 9 months. Weight, BMI, 24-hour dietary recall, drug consumption and vomiting episodes were recorded and compared with nutritional outcome.

A new technique for percutaneous gastrostomy of a decompressed excluded gastric segment after Roux-en-Y gastric bypass (RYGBP) surgery is described and the results in a single institution are reviewed. Computed tomography guidance was used to place a 21-or 22-gauge needle into the lumen of the stomach and distend it to allow placement of a feeding catheter. Ten women underwent the procedure, and despite only three patients having clear access windows, gastrostomy placement was ultimately successful in all 10 patients. Percutaneous gastrostomy of the decompressed excluded gastric segment after RYGBP surgery can be challenging, but a high rate of success can be achieved.

Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion. Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeuti...

Background Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG. Methods A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Rouxen-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary-care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change. Results There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P < 0.0001). There were significant differences in OT between the MSA and RYGB groups (P < 0.0001) and MSA-S and RYGB groups (P = 0.009), but not MSA group to MSA-S group (P = 0.51). There was no significant difference in intraoperative and postoperative morbidity (P = 1.0 and P = 0.60, respectively). 30-day morbidity: 5.6% (MSA), 15.4% (MSA-S) and 15% (RYGB). There was no difference on PPI discontinuation among groups, with more than 80% success rate in all. Conclusions The use of the robotic platform in the different approaches available for treatment of GERD after SG appears to be a feasible option with low morbidity and high success rate. Further data is needed to support our findings.

Background: Reported morbidity of Roux-en-Y gastric bypass in patients with previous antireflux surgery warrants caution, and data on sleeve gastrectomy (SG) are unexpectedly scarce. Objectives: To evaluate the safety and efficiency of SG in patients who previously underwent an antireflux procedure. A new technique to preserve intact fundoplication is described. Setting: Private practice, bariatric center of excellence, Turkey. Methods: The following data were retrieved from our prospective data base: (1) details of previous repair; (2) clinical/endoscopic reflux status, body mass index (kg/m 2), and presence of metabolic syndrome (MetS) and type 2 diabetes (T2D) before SG; (3) duration of SG, length of stay, complications; and (4) percent excess weight loss, MetS/T2D resolution, and reflux status at follow-up. Results: Fifteen consecutive SGs were performed without conversion or major complications. The first case is excluded from the analysis because complete wrap unfolding was abandoned in favor of the described technique. Among 14, 10 had MetS, 4 had T2D, and 1 had a proven reflux recurrence before SG. Mean operating time was 118.5 minutes. All were discharged on the third postoperative day. Apart from 1 functional stenosis, no complications occurred. At 12 months, percent excess weight loss rate was 82.2, MetS resolved in 9 of 10, and T2D was in complete (n 5 2) or partial remission (n 5 1). No de novo reflux became evident, and absence of reflux was proved by pHmeter in 3. Conclusions: SG is feasible in patients who previously had antireflux repair with negligible morbidity and percent excess weight loss rates similar to that with regular sleeves. Results in reflux control needs further confirmation.

Hypothesis: Circulating ghrelin, produced primarily in the stomach, is a powerful orexigen. Ghrelin levels are elevated in states of hunger, but rapidly decline postprandially. Early alterations in ghrelin levels in morbidly obese patients undergoing weight reduction surgery may be attributed to gastric partitioning. Design and Patients: Thirty-four patients underwent Roux-en-Y gastric bypass with a completely divided gastroplasty to create a 15-mL vertically oriented gastric pouch. Eight other patients underwent other gastric procedures that did not involve complete division of the stomach, including 4 vertical banded gastroplasties and 4 antireflux surgical procedures. Six additional patients undergoing antireflux surgery served as lean control subjects. Plasma samples were obtained before surgery and immediately after surgery. In a substudy, plasma was collected after Rouxen-Y limb formation and after dividing the stomach to identify any changes in plasma ghrelin levels. Setting: Tertiary university medical center. Main Outcome Measures: Ghrelin levels at different stages of surgical intervention.

1.8Ϯ0.4, and 2.9Ϯ1.0 kg/month, pϭ0.0001. The ratios for lean to fat loss among the respective tertiles were 1:4.0, 1:3.6 and 1:3.0. The correlation between rates of lean and fat mass loss was rϭ0.37, pϭ0.04. Only three of the 32 patients (9.4%) patients maintained or gained lean mass following RYGB surgery. Conclusion: After bariatric surgery, those patients losing weight at the greatest rate demonstrate accelerated losses of both lean and fat mass. Few patients maintain lean body mass after bariatric surgery, despite self-reported participation in conventional exercise programs. These data suggest the need for more aggressive interventions to preserve lean body mass during the weight loss phase after RYGB surgery.

Background. Revision of failed bariatric procedures is a significant challenge for bariatric surgeons, because of the increasing number of recurring morbid obesity or complications, especially in patients with a previous Vertical Banded Gastroplasty (VBG). Methods. Since November 1998, 109 patients with failed or complicated VBG were followed in a retrospective study. 49 patients underwent re-VBG and, since 2004, 60 underwent Roux-en-Y Gastric Bypass-on-Vertical Banded Gastroplasty (RYGB-on-VBG). Results. At 3 years follow-up, mean BMI decreased from 37.4 to 31.2 Kg/m 2 in the first group, and from 35.0 to 28.4 Kg/m 2 in the second. Early complications were 7 (14.3%) in the first group and 4 (6.5%) in the second; late complications were 33 (59.1%) and 11 (18.3%), respectively. Conclusion. Although both operations seem to be effective as bariatric revision procedures in terms of BMI, the mid-term outcomes of RYGB-on-VBG demonstrate the lowest rate of complications and better quality of life.

Purpose Metabolic syndrome in patients with morbid obesity causes a higher cardiovascular morbidity, eventually leading to left ventricular hypertrophy and decreased left ventricular ejection fraction (LVEF). Roux-en-Y gastric bypass (RYGB) is considered the gold standard modality for treatment of morbid obesity and might even lead to improved cardiac function. Our objective is to investigate whether cardiac function in patients with morbid obesity improves after RYGB. Materials and Methods In this single center pilot study, 15 patients with an uneventful cardiac history who underwent RYGB were included from May 2015 to March 2016. Cardiac function was measured by cardiac magnetic resonance imaging (CMRI), performed preoperatively and 3, 6, and 12 months postoperative. LVEF and myocardial mass and cardiac output were measured. Results A total of 13 patients without decreased LVEF preoperative completed follow-up (mean age 37, 48.0 ± 8.8). There was a significant decrease of cardiac ...

Background: One problem with Roux-en-Y gastric bypass (RYGBP) is that it leaves the bypassed segment not readily available for endoscopic or radiographic examinations. Materials and Methods: Three males, 50, 54 and 64 years old, suffered from repeated, gastrointestinal bleeding of unknown origin requiring transfusion 1/2, 1 and 7 years after RYGBP. Access to the stomach was obtained by an ultrasound-guided percutaneous gastrostomy. Results: We could perform endoscopy, barium studies and gastric acid output measurements through the gastrostomy. Histological gastritis, low acid output and absence of H. pylori infection were found. Conclusion: We were able to exclude severe gastric disease in our patients.

Objective To explore the role of hormones and the autonomic nervous system in the rapid remission of diabetes after Roux-en-Y Gastric Bypass (RYGB). Research design and methods Nineteen obese patients with type 2 diabetes, 7 M/12 F, were randomized (2:1) to RYGB or standard-of-care medical treatment (control). At baseline and 4 and 24 weeks post surgery, fasting blood sampling, OGTT, intravenous arginine challenge, and heart-rate variability (HRV) assessments were performed. Results At both 4 and 24 weeks post-RYGB the following effects were found: arginine-stimulated insulin secretion was reduced. GLP-1, GIP, and glucagon rise during OGTT was enhanced. IGF-1 and GH levels increased. In addition, total HRV and spectral components PLF (power of low frequency) and PHF (power of high frequency) increased. At 4 weeks, morning cortisol was lower than baseline and 24 weeks. At 24 weeks, NEFA levels during OGTT, and the PLF/PHF ratio decreased. None of these changes were seen in the contro...

Background: The surgical treatment of morbidly obese patients with a body mass index (BMI) Ͼ50 kg/m 2 (super obese) with significant co-morbidities remains a challenge. We evaluated the outcomes after initial laparoscopic sleeve gastrectomy (LSG) in these patients undergoing 2-stage procedures. Methods: We identified all patients (BMI Ͼ50 kg/m 2) who had undergone LSG as a part of a 2-stage procedure, from 2005 to 2008, from our prospectively maintained database. The patient demographics and co-morbidities were noted, and we analyzed the morbidity and length of stay. Weight loss after the initial procedure was tracked and the BMI at the decision for the second stage noted. Results: A total of 59 patients with a BMI Ͼ50 kg/m 2 (median 60, range 50-81.5) underwent sleeve gastrectomy as a part of a 2-stage procedure for obesity during this period. The median age was 41.5 years (range 21-61.5), and 37 were women (male/female ratio 3:5). The co-morbidities of diabetes, hypertension, and obstructive sleep apnea were present in different combinations in 44 patients (74.6%). All the procedures were completed laparoscopically, barring in 1 patient who had undergone previous fundoplication. The median length of stay was 4 days (interquartile range 3-6). Complications occurred in 8 patients (13.5%), and 4 patients required repeat laparoscopy for staple line leak or bleeding. No mortality occurred. The median weight loss at 1 year was 42.4 kg (interquartile range 30.3-60.2). Diabetes and obstructive sleep apnea resolved, and hypertension resolved in 70% patients. Of the 59 patients, 33 went on to have a second-stage procedure. The rest, who had undergone LSG in 2008 were still losing weight and the decision to proceed to the second stage had not been made at last follow-up. Of the 33 patients who had a second-stage procedure, 2 underwent Roux-en-Y gastric bypass, 2 underwent repeat sleeve gastrectomy, and 29 underwent duodenal switch. All the procedures were performed laparoscopically. Conclusions: LSG is a safe and effective procedure for initial weight loss in the super-obese undergoing 2-stage procedures.