History Of Roux-en-Y Gastric Bypass Research Articles

Rates of Recurrent Marginal Ulcer in Gastric Bypass Patients Undergoing Revisional Surgery.

The rate of marginal ulcer (MU) following primary Roux-en-Y Gastric Bypass (RYGB) is approximately .6-16%. Few studies have evaluated recurrence rates following surgical revision for MU. The primary aim of this study was to determine the rate of MU recurrence following revision. The secondary aim was to evaluate the impact of truncal vagotomy (TV) on the recurrence rates and analyze potential risk factors associated with the recurrence of MU after revision. We conducted a retrospective cohort study examining data at a single tertiary academic medical center. Adult patients with a history of RYGB who underwent gastrojejunostomy revision for recurrent MU between the years of 2003-2020 were included. We sought to determine our overall rate of MU following revision, with and without TV. Additionally, we examined the association of risk factors with MU recurrence. Fisher's exact test was used to determine the statistical significance of recurrence rates between the groups. We included 90 patients in the study. The overall recurrence rate for MU was 16.7%. Of the 90 patients, 35 (35.4%) patients underwent TV at the time of revision. The recurrence rate of MU after GJ revision with TV was 14.3% in comparison to those without TV, 18.2% (P = .775). Smoking, steroid, alcohol use, history of cardiac surgery/intervention, and helicobacter pylori were not significantly associated with recurrent MU following revision. The rate of recurrence after revision for MU is high. Adding TV trended towards decreased MU recurrence after revisional surgery, however not significant. Larger studies are needed to evaluate risk factors associated with recurrent MU after revision.

Effects of Heterozygous Variants in the Leptin-Melanocortin Pathway on Roux-en-Y Gastric Bypass Outcomes: a 15-Year Case-Control Study.

Heterozygous variants in the leptin-melanocortin pathway are associated with obesity. However, their effect on the long-term outcomes after Roux-en-Y gastric bypass (RYGB) is still unknown. In this matched case-control study, 701 participants from the Mayo Clinic Biobank with a history of RYGB were genotyped. Sixty-three patients had a heterozygous variant in the leptin-melanocortin pathway. After excluding patients with potential confounders, carriers were randomly matched (on sex, age, body mass index [BMI], and years since surgery) with two non-carrier controls. The electronic medical record of carriers and matched non-carriers was reviewed for up to 15years after RYGB. A total of 50 carriers and 100 matched non-carriers with a history of RYGB were included in the study. Seven different genes (LEPR, PCSK1, POMC, SH2B1, SRC1, MC4R, and SIM1) in the leptin-melanocortin pathway were identified. At the time of surgery, the mean age was 50.8 ± 10.6years, BMI 45.6 ± 7.3kg/m2, and 79% women. There were no differences in postoperative years of follow-up, Roux limb length, or gastric pouch size between groups. Fifteen years after RYGB, the percentage of total body weight loss (%TBWL) in carriers was - 16.6 ± 10.7 compared with - 28.7 ± 12.9 in non-carriers (diff = 12.1%; 95% CI, 4.8 to 19.3) and the percentage ofweight regain after maximum weight loss was 52.7 ± 29.7 in carriers compared with 29.8 ± 20.7 in non-carriers (diff = 22.9%; 95% CI, 5.3 to 40.5). The nadir %TBWL was lower - 32.1 ± 8.1 in carriers compared with - 36.8 ± 10.4 in non-carriers (diff = 4.8%; 95% CI 1.8 to 7.8). Carriers of a heterozygous variant in the leptin-melanocortin pathway have a progressive and significant weight regain in the mid- and long-term after RYGB. Genotyping patients experiencing significant weight regain after RYGB could help implement multidisciplinary and individualized weightloss interventions to improve weight maintenance after surgery.

Diagnostic accuracy of a fast MRI T2-sequence for the diagnosis of internal herniation after Roux-and-Y gastric bypass during pregnancy: A retrospective single center study

PurposeThe objective of this retrospective study was to evaluate the diagnostic accuracy of a fast sequence Magnetic Resonance Imaging (MRI) sequence, T2- half-Fourier acquisition single-shot turbo spin echo (HASTE) for the diagnosis of internal herniation (IH) in pregnant patients with a history of Roux-en-Y gastric bypass (RYGB). MethodsAbdominal MRI studies, performed for the clinical suspicion of IH of pregnant patients with a history of RYGB, were analyzed by two abdominal radiologists. Thirty-one cases were included and for each case both readers independently evaluated the T2 HASTE sequence in different planes (axial, coronal and sagittal) to determine the presence or absence of IH. Diagnostic performance of T2 HASTE MRI was evaluated by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy compared to the clinical diagnosis of IH as the gold standard. IH was diagnosed as the presence of herniated bowel through the mesenteric defect at the time of surgical exploration. IH was deemed absent if the surgical exploration showed no herniated bowel or if patients had no subsequent clinical symptoms of IH after 90 days of clinical follow-up. ResultsThe results in this study, with 16 patients with IH and 15 patients without IH, portray a high accuracy for the detection of IH, ranging from 87.9% to 90.3%. This fast T2 sequence shows a high NPV (86.7% - 100.0% 87.7), sensitivity (88.9% - 100.0%) and specificity (80.0% - 86.7%). This study also portrayed a substantial interobserver agreement (0.741) for the evaluation of IH. ConclusionT2 HASTE MRI shows an excellent sensitivity and NPV for the detection of IH in pregnant patients. The fast acquisition time makes this sequence useful in the emergency setting, and it can be used for the diagnosis or exclusion of IH in pregnant patients.

A Prospective Study of Association of Micronutrients Deficiencies during Pregnancy and Neonatal Outcome among Women after Bariatric Surgery.

Little is known about the association of micronutrients deficiencies during pregnancy and neonatal outcome among women after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). We present a prospective study of 87 consecutive women with a history of RYGB (n = 37) or SG (n = 50) who underwent complete and regular clinical and biological nutritional assessments during pregnancy. Data on maternal characteristics, biological nutritional parameters, antenatal management, and perinatal outcome were collected. The objective was to evaluate serum levels of micronutrients at the second trimester, and to assess the association between micronutrients deficiencies and neonatal outcome. After RYGB, maternal age (34.3 ± 4.9 vs. 31.1 ± 4.6 years; p = 0.003) and pregnancy timing after surgery (64.5 ± 47.0 vs. 38.1 ± 28.1 months; p = 0.002) were significantly higher, and pre-pregnancy BMI was significantly lower (29.8 ± 5.6 vs. 32.9 ± 7.1 kg/m2; p = 0.03). Maternal and neonatal outcomes were similar. Additional supplementations after blood tests were similar in groups. Zinc, selenium, vitamins A1, B1, B6, C, and E levels were not different depending on the type of surgery. Zinc deficiency (7/87) was significantly more frequent after RYGP (18.9% vs. 0%; p = 0.02) and selenium deficiency (15/87) was similar in groups (21.6% after RYGB and 14.0% after SG; p = 0.36). The mean birth weight was significantly lower in selenium deficiency cases (3137 ± 550 vs. 3535 ± 737 g; p = 0.04). Selenium deficiency was negatively correlated with birth weight (r = −0.23; p = 0.03) and with birth weight z-score (r = −0.26; p = 0.01), but not correlated after adjustment for the procedure. The levels of micronutrients surveillance along pregnancy in women with a history of bariatric surgery is necessary to decrease the risk of inadequate fetal growth in the patients.

S1854 Endoscopic Retrograde Cholangiopancreatography in Patient With Roux-en-Y Gastric Bypass and High-Grade Duodenal Stricture Across Dual Lumen Apposing Metal Stents

INTRODUCTION: Endoscopic ultrasound-guided lumen-apposing metal stents (LAMS) is a minimally invasive modality that has not only been used for drainage of pancreatic fluid collection but also other off-label indications. We demonstrated a case with multiple applications of LAMS for management of both choledocholithiasis and enteric stricture in a patient with Roux-en-Y Gastric Bypass (RYGB) anatomy. CASE DESCRIPTION/METHODS: An 82-year-old woman with a history of RYGB, multiple abdominal surgeries and choledocholithiasis, which was treated with laparoscopic-assisted ERCP (LA-ERCP) and complicated by duodenal perforation and repaired by open surgery, was admitted for right upper quadrant abdominal pain. MRCP revealed choledocholithiasis with biliary dilatation. After discussion of various options for accessing biliary system, EDGE procedure was pursued. For the initial stage, LAMS was deployed to obtain access to gastric remnant under endosonographic and fluoroscopic guidance. The patient returned in 3 weeks after the tract was mature for ERCP. However, high-grade duodenal stricture, which is likely due to post-surgical scarring or peptic stricture, was unexpectedly found before reaching the biliary system. The stricture was treated with 20 mm by 10 mm LAMS placement under endosonographic and fluoroscopic guidance. She returned in 2 weeks for subsequent ERCP through dual transluminal connection consisted of gastrogastrostomy and duodenal LAMS. The duodenoscope was advanced through gastrogastrostomy and duodenal LAMS to the major papilla without difficulty. Biliary sphincterotomy and plastic biliary stent placement were performed. A large amount of sludge and stone was extracted. She was discharged the same day with improvement in symptoms. All stents were removed 6 weeks after the ERCP without complications. DISCUSSION: With application of LAMS, we described a novel case of EDGE procedure in patient with RYGB anatomy in conjunction with benign enteric stricture, which was performed through dual transluminal conduit comprised of gastrogastrostomy and duodenal LAMS. Other biliary access options were also considered. However, given the high likelihood of extensive adhesions from prior abdominal surgery, LA-ERCP posed a higher risk of complications, and balloon-assisted enteroscopy ERCP (BA-ERCP) has limited maneuverability which often leads to suboptimal success rates. This highly effective approach should be considered for situations where BA-ERCP is technically challenging, and when LA-ERCP is not feasible.

Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass.

Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. Stanford University Hospital and Clinics. Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.

EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB.

Background and study aims Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is a novel technique for managing pancreaticobiliary diseases in patients with a history of Roux-en-Y Gastric Bypass (RYGB). It has shown to have high technical success rates and fewer adverse events as compared to laparoscopic-assisted ERCP (LA-ERCP). We compared the technical success and clinical outcomes of EDGE vs. LA-ERCP vs. E-ERCP. Patients and methods A retrospective chart review was performed for 56 patients, of whom 18 underwent LA-ERCP, 12 underwent E-ERCP, and 26 had EDGE, and a comparison of technical success and complication rates was done. Results Baseline demographic characteristics of patients undergoing these procedures, including age and gender, were comparable. The technical success rate for patients in the EDGE group were 100 % (n = 26), compared with 94 % (n = 17) and 75 % (n = 9) in the LA-ERCP and E-ERCP groups ( P = 0.02). In the EDGE group, 8 % of patients (n = 2) had bleeding, and 4 % of patients (n = 1) had lumen-apposing metal stent migration occur during the procedure. In the LA-ERCP group 6 % (n = 1) of patient had bleeding, 6 % (n = 1) post-ERCP pancreatitis and 6 % (n = 1) were diagnosed with an intra-abdominal infection post-procedure. Time to complete the EDGE procedure was significantly shorter at 79 ± 31 mins, compared with 158 ± 50 mins for LA-ERCP and 102 ± 43 mins for E-ERCP ( P < 0.001). Conclusion EDGE is a novel procedure with short procedure times and an effective alternative to LA-ERCP and E-ERCP in management of pancreaticobiliary diseases in patients with a history of RYGB.

2185 69-Year-Old Male After Gastric Bypass With Choledocholithiasis Treated With EDGE Procedure Complicated by LAMS Dislocation

INTRODUCTION: With the alarming increase in the prevalence of obesity, more people are undergoing bariatric surgeries of which most common is Roux-en-Y gastric bypass (RYGB). This altered anatomy poses challenges in accessing the papilla for ERCP in the setting of biliary pathology. Until recently enteroscopy or surgery assisted ERCP were the two main treatment options. Today, EUS-directed trans-gastric ERCP (EDGE) procedures have emerged as a promising treatment option in such circumstances. CASE DESCRIPTION/METHODS: A 69-year-old male with history of RYGB, cholecystectomy, Barret’s esophagus, CAD and CKD was admitted with one day history of vomiting and RUQ abdominal pain. On initial evaluation the patient was afebrile, normotensive with scleral icterus. Labs were significant for leukocytosis (14.2 10^3/µL), elevated transaminases (AST 254 U/L; ALT 231 U/L) and signs of biliary obstruction (ALP 252 U/L; bilirubin 3.3 mg/dl). Abdominal imaging (CT, US) revealed dilated intra and extra hepatic biliary ducts with the CBD measuring 1.4cm. For further evaluation, an EDGE procedure was performed within 24 hours. After injecting water to form a fluid collection in the stomach and confirming no blood flow in the path, a 20mm Hot Axios LAMS was successfully deployed under EUS guidance. The gastric lumen was confirmed after dilatation to 18mm. The duodenoscope was advanced and subsequent cholangiogram revealed several large stone filling defects along with dilated hepatic ducts. A sphincterotomy was performed, 9-12mm followed by 12-15mm extraction balloons were advanced over the wire and after multiple sweeps, 5 large stones were removed with resolution of biliary obstruction. During the ERCP, the LAMS dislodged into the native stomach over the scope but was able to be successfully removed by rat-tooth forceps. Finally, the fistula was closed using endo-clips and the patient reported resolution of his symptoms and LFTs normalized. DISCUSSION: Choledocholithiasis after RYGB is not unusual as nearly 50% of patients develop biliary stones within two years after surgery. The most common complications after EDGE procedure are bleeding from the fistula site, persistent fistula formation, perforation or adverse events related to ERCP. We present a rare case of LAMS dislocation into the stomach during EDGE which was successfully removed with the snare. Being able to recognize and immediately treat this potential complication may help providers anticipate it during EDGE procedures.

2409 A Rare Complication of Gastric Bypass in the Setting of Chronic Liver Disease

INTRODUCTION: Porto-mesenteric venous thrombosis (PMVT) is a known and potentially fatal complication of general surgery. However, it has been rarely reported as a complication of worsening liver disease after undergoing bariatric surgery. This is a case of a patient who presented with mesenteric thrombosis following Roux-en-y gastric bypass (RYGB). CASE DESCRIPTION/METHODS: Patient is a 42-year-old African American female with a history of RYGB who presented with episodes of post-operative abdominal pain for 5 years. She was found to have recurrent high-grade small bowel obstruction's (SBO) necessitating a small bowel resection. Her course was further complicated by intra-abdominal abscesses requiring computed tomography (CT)-guided drainage, and wound dehiscence requiring open surgical intervention and debridement. Four months after discharge, she presented with right-sided abdominal pain and acute encephalopathy. Liver enzymes were elevated. Abdominal ultrasound revealed portal vein thrombosis (PVT). Dual-phase CT of the abdomen revealed sub-acute to chronic complete diffuse mesenteric thrombosis with collateralizations involving the portal, splenic, and distal superior mesenteric veins. Given that previous imaging suggested steatosis and hepatomegaly, sub-acute liver injury secondary to thrombosis was established in the setting of chronic liver disease. The patient's underlying non-alcoholic fatty liver disease was likely worsened by severe malnutrition and short gut syndrome following the RYGB. Her hepatic encephalopathy resolved after initiating lactulose and rifaximin. Outpatient hematology evaluation for all causes of thrombophilia remained inconclusive and the patient had no recurrences of thrombosis. DISCUSSION: RYGB remains the gold standard for bariatric surgery as it results in the most durable weight loss. However, complications may occur such as gastrointestinal leak, fistulas, marginal ulcers, SBO, and dumping syndrome. Mechanisms of thrombosis formation in this setting could be related to intra-operative vascular manipulation, increased intra-abdominal pressure, venous stasis, and possibly deteriorating liver function secondary to rapid weight loss and malnutrition. PMVT hasn't been reported consistently as a complication in various bariatric surgery studies, which leads us to conclude that it's either under or mis-diagnosed. It is extremely important to consider PMVT as a complication of RYGB in patients who have evidence of underlying liver disease prior to undergoing RYGB.

2188 Off-label Use of Lumen-Apposing Metal Stent for Gastro-Jejunal Anastomotic Stricture Following Roux-en-y Gastric Bypass

INTRODUCTION: Roux-en-y gastric bypass (RYGB) is the second most common bariatric surgery performed after sleeve gastrectomy. A complication of this procedure is a gastrojejunal (GJ) anastomotic stricture. A lumen apposing metal stent (LAMS), which was initially used for draining pancreatic fluid collections/cystogastrostomy, is now being used in various locations throughout the gastrointestinal tract due to its novel dumbbell shaped design. In this case report we present a case of GJ anastomotic stricture successfully managed with LAMS after failure of serial balloon dilations. CASE DESCRIPTION/METHODS: A 51-year-old woman with a history of RYGB in 2008, complicated by recurrent stricture of her GJ anastomosis, presented for treatment options of her stricture. She had undergone dilations in the past with no change in her symptoms of daily vomiting. The patient requested a more definitive treatment. The patient was taken for placement of a LAMS endoscopically. Her stricture at the GJ anastomosis measured 7mm in diameter and &lt;1 cm in length. A hydrophilic wire was inserted into the jejunum under fluoroscopic guidance. A 15mm LAMS was advanced over the wire into the jejunal lumen. Placement was confirmed with endoscope and fluoroscopic image. Finally, a 12-13.5-15 mm CRE balloon was advanced over the wire and used to dilate the lumen of the stent. The patient returned to the clinic 5 weeks later with complete resolution of her symptoms. She will have the stent removed in 2 weeks. DISCUSSION: GJ anastomoses can initially be managed with pneumatic dilations. However, this requires repeat interventions with limited success. A common alternative is the fully covered self-expanding metal stent (FCSEMS). The FCSEMS has a high rate of adverse events including stent migration, perforation, and recurrence of strictures after removal. A LAMS has a novel dumbbell shape design that prevents leakage and migration due to 24 mm anchoring flanges, while also being shorter and smaller than FCSEMS. Additionally, because of the dumbbell shape, when inflated with a CRE balloon, the risk of migration is very low. For these reasons, in addition to its expanding use within the GI tract, it was used in our patient with success. This case demonstrates another use for LAMS that is safe and effective in an expanding population.

Pancreaticoduodenectomy in Patients with Previous Roux-en-Y Gastric Bypass: a Matched Case-Control Study.

Little has been reported regarding outcomes of pancreaticoduodenectomy (PD) in patients with previous Roux-en-Y gastric bypass (RYGB). We performed a retrospective case-control study of patients undergoing PD after RYGB from January 2012 through July 2017 at 2 institutions. Of the 380 patients who underwent PD, 12 (3.2%) had previous RYGB. They were matched (by age, sex, diagnosis, operative approach, and year of surgery) to 36 non-RYGB patients undergoing PD (1:3 ratio). No difference was found between groups in mean operative time, length of hospitalization, or postoperative morbidity. A history of RYGB in patients with pancreatic head pathology did not delay surgical intervention. Outcomes of PD were similar for patients who did or did not have prior RYGB.

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.

Comparison of oral antibiotic failure rates in post-Roux-en-Y gastric bypass patients versus controls

BackgroundDue to the malabsorptive nature of the Roux-en-Y gastric bypass (RYGB), there is a potential for impaired absorption of oral medications. Clinical outcomes of patients who receive oral antibiotics after RYGB have not been adequately described in the literature. ObjectivesThe primary objective was composite therapeutic failure. Secondary objectives included comparing failure rates between antibiotic classes and at various time points since RYGB. SettingUniversity hospital, United States. MethodsPatients with a history of RYGB and controls who received an eligible oral antibiotic for urinary tract infection, skin and soft tissue infection, or community acquired pneumonia between April 1, 2008, and September 30, 2015, were included via retrospective chart review. Therapeutic failure rates between groups were compared and adjusted for body mass index and infection type. Failure rates among antibiotic classes and various time points since RYGB (0–1 yr, 1–1.9 yr, and≥2 yr) were also compared. ResultsA total of 58 RYGB and 128 controls met inclusion and exclusion criteria. Composite therapeutic failure occurred in the RYGB and control group in 14 (24.1%) and 20 patients (15.6%), respectively (P = .18; odds ratio, 1.8; 95% confidence interval .8–4.4). RYGB patients who received fluoroquinolones or sulfonamides had a significantly increased risk of therapeutic failure. ConclusionsRYGB was not associated with a statistically significant increased risk of composite therapeutic failure of oral antibiotics in the treatment of urinary tract infection, skin and soft tissue infection, or community acquired pneumonia compared with patients with no history of gastrointestinal resection. Further research is warranted to understand clinical outcomes of RYGB patients who receive oral antibiotics.

Laparoscopy-Assisted Trans-Gastric Rendez-vous for the Treatment of Common Bile Duct Stones in Patients with Prior Roux-en-Y Gastric Bypass

Common bile duct (CBD) stones in a Roux-en-Y gastric bypass (RYGB) represent a major challenge for ERCP due to long-limb anatomy. Trans-gastric approach has been proposed but entails high ERCP-related risks. Laparoscopy assisted trans-gastric rendez-vous (LATG-RV) is a one-step procedure that may lower the risks of these patients. We describe our initial experience in four patients with past history of RYGB and CBD stones. All patients underwent LATG-RV and had successful CBD stone clearance. Postoperative course was uneventful with normal amylase levels. Average procedure time was 105min and postoperative stay 2days. LATG-RV is a safe and effective procedure for the clearance of CBD stones in RYGB patients. It may have fewer complications and shorter operative time than regular trans-gastric ERCP.

Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome with Gastric Bypass Reversal: A Case Report and Review of the Literature.

Background. Roux-en-Y gastric bypass (RYGB) is a commonly performed, effective bariatric procedure; however, rarely, complications such as postprandial hypoglycemia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) may ensue. Management of refractory NIPHS is challenging. We report a case that was successfully treated with RYGB reversal. Case Report. A 58-year-old male with history of RYGB nine months earlier for morbid obesity presented for evaluation of postprandial, hypoglycemic seizures. Testing for insulin level, insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, and cortisol stimulation was unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fast was completed without hypoglycemia. Mixed meal testing demonstrated endogenous hyperinsulinemic hypoglycemia (EHH) and selective arterial calcium stimulation testing (SACST) was positive. Strict dietary modifications, maximal medical therapy, gastrostomy tube feeding, and stomal reduction failed to alleviate symptoms. Ultimately, he underwent laparoscopic reversal of RYGB. Now, 9 months after reversal, he has markedly reduced hypoglycemia burden. Discussion. Hyperfunctioning islets secondary to exaggerated incretin response and altered intestinal nutrient delivery are hypothesized to be causative in NIPHS. For refractory cases, there is increasing skepticism about the safety and efficacy of pancreatic resection. RYGB reversal may be successful.

Case review and consideration for imaging and work evaluation of the pregnant bariatric patient

BackgroundThere is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB. MethodsAfter Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB and abdominal distress. ResultsFive patients were identified. Patient age ranged from 22–34 years (mean 28.4). Gestational age ranged from 9–31 months (mean 19.2). Average body mass index at presentation was 30.3 kg/m2. Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Four patients were taken to the operating room. One was successfully discharged. Two of the patients had an obstruction from adhesions, and the other 2 were found to have internal hernia. There was no mortality for either fetus or mother. One patient required premature delivery at 28 weeks. ConclusionsPregnant women with history of RYGB who present with abdominal pain should be evaluated urgently for internal hernia or obstruction. A systematic approach is needed to ensure prompt diagnosis.

Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss

BackgroundPatients having previous bariatric surgery are at risk for weight regain and return of co-morbidities. If an anatomic basis for the failure is identified, many surgeons advocate revision or conversion to a Roux-en-Y gastric bypass. The aim of this study was to determine whether revisional bariatric surgery leads to sufficient weight loss and co-morbidity remission. Patients and MethodsFrom 2005-2012, patients undergoing revision were entered into a prospectively maintained database. Perioperative outcomes, including complications, weight loss, and co-morbidity remission, were examined for all patients with a history of a previous vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGB). ResultsTwenty-two patients with a history of RYGB and 56 with a history of VBG were identified. Following the revisional procedure, the RYGB group experienced 35.8% excess weight loss (%EWL) and a 31.8% morbidity rate. For the VBG group, patients experienced a 46.2% %EWL from their weight before the revisional operation with a 51.8% morbidity rate. Co-morbidity remission rate was excellent. Diabetes (VBG:100%, RYGB: 85.7%), gastroesophageal reflux disease (VBG: 94.4%, RYGB: 80%), and hypertension (VBG: 74.2%, RYGB:60%) demonstrated significant improvement. ConclusionRevision of a failed RYGB or conversion of a VBG to a RYGB provides less weight loss and a higher complication rate than primary RYGB but provides an excellent opportunity for co-morbidity remission.

Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass

Marginal ulcer formation remains a significant complication of Roux-en-Y gastric bypass (RYGB). Up to 1 % of all RYGB patients will develop free perforation of a marginal ulcer. Classically, this complication has required anastomotic revision; however, this approach is associated with significant morbidity. Several small series have suggested that omental patch repair may be effective. The aim of this study was to examine the management of perforated marginal ulcers following RYGB. All patients who underwent operative intervention for perforated ulcers between 2003 and 2011 were reviewed. Those with a history of RYGB with perforation of a marginal ulcer were included in the analysis. Data collected included operative approach, operative time, blood loss, length of hospital stay, complications, smoking history, and steroid or NSAID use. From January 2003 to December 2011, a total of 1,760 patients underwent RYGB at our institution. Eighteen (0.85 %) developed perforation of a marginal ulcer. Three patients' original procedure was performed at another institution. Eight patients (44 %) had at least one risk factor for ulcer formation. Treatment included omental patch repair (laparoscopic, n = 7; open, n = 9) or anastomotic revision (n = 2). Compared to anastomotic revision, omental patch repair had shorter OR time (101 ± 57 vs. 138 ± 2 min), decreased estimated blood loss (70 ± 72 vs. 250 ± 71 mL), and shorter total length of stay (5.6 ± 1.4 vs. 11.0 ± 5.7 days). Perforated marginal ulcer represents a significant complication of RYGB. Patients should be educated to reduce risk factors for perforation, as prolonged proton pump inhibitor therapy may not prevent this complication in a patient with even just one risk factor. In our sample population we found laparoscopic or open omental patch repair to be a safe and effective treatment for this condition and it was associated with decreased operative time, blood loss, and length of stay.

Surgical Gastrostomy for Pancreatobiliary and Duodenal Access Following Roux en Y Gastric Bypass

BackgroundPancreatobiliary access following Roux-en-Y gastric bypass (RYGBP) is challenging. We reviewed 32 cases of surgical gastrostomy for complex transgastric upper gastrointestinal endoscopy. MethodsRetrospective review of prospectively collected database of patients with history of RYGBP that had surgical gastrostomy for pancreatobiliary and duodenal access at a single institution from 2004–2008. Indication for procedure, surgical findings, successful cannulation, and complications are reported. ResultsThirty patients (25 female), with age ranging from 27 to 72, underwent 32 procedures. The indications to access the gastric remnant were sphincter of Oddi dysfunction (13), pancreatitis (six), common bile duct stone/obstruction (five), cholangitis (three), pancreatic mass evaluation (two), gastrointestinal bleed (two), and cystic duct leak after cholecystectomy (one). Mean operative time was 200 min (98–338) and estimated blood loss (mean) 85 cc (10–500). Laparoscopic gastrostomy was attempted in 28 cases with one conversion to open (3.6%). Four planned open procedures were also performed. All 30 patients underwent successful endoscopy and 28 had an endoscopic retrograde cholangiopancreatography, all with successful cannulation of the pancreatobiliary tree (100%). ConclusionsSurgical gastrostomy is an effective means to gain access to the upper GI tract and pancreatobiliary tree following RYGBP. This technique should be considered when traditional endoscopic approaches are impossible.

Endoscopic Evaluation of the Defunctionalized Stomach Using Shapelock Technology

Background/Aims: Roux-en-Y gastric bypass (RYGB) patients present a unique problem if they require diagnostic or therapeutic interventions for which the defunctionalized stomach must be endoscopically accessed. Due to the acute angulation of the jejuno-jejunal (JJ) anastomosis, traditional enteroscopy rarely allows visualization of the proximal afferent limb and defuntionalized stomach. Novel shape-locking guides (ShapeLock, USGI, San Clemente, CA) have been reported in the literature to reduce looping during colonoscopy. Our goal is to utilize this technology to permit endoscopic evaluation of the defuntionalized stomach. Materials: The ShapeLock Enteroscopy Device consists of two components: (1) a reusable titanium link body with squeeze activated handle (2) a sterile disposable sheath with smooth external skin, hydrophilic coated inner liner and foam tip. The device is inserted over the scope in a flexible state and when locked, becomes rigid in the shape of the scope. In the locked state, the ShapeLock provides a stable conduit to direct the push forces of the scope without further stretching or looping. The device used for this study was 100 cm long and has an O.D. of 16 mm. Methods: Four patients with history of RYGB were referred for repeat endoscopic evaluation after initial upper enteroscopy failed to reach the excluded stomach. After achieving appropriate levels of sedation, a standard upper enteroscope was overloaded with the ShapeLock and inserted through the mouth. The device was advanced through the gastro-jejunal (GJ) anastomosis, down the Roux limb and then inserted into the distal pancreato-biliary limb. The device was then locked, allowing the enteroscope to pass the acute angulation of the anastomosis and move deeply into the pancreato-biliary limb and the defunctionalized stomach. Results: The ShapeLock was able to be advanced to the excluded stomach and perform a thorough examination and biopsy in 3 out of 4 patients. In these 3 patients there was minimal erythema at the JJ anastomosis upon withdrawal of the enteroscope. Additionally, 2 of these patients had minimal erythema at the GJ anastomosis. There were no significant mucosal defects indicative of trauma. In one patient the diameter of the GJ anastomosis prevented passage of the device. Conclusions: The ShapeLock device can allow access to the entire upper gastrointestinal tract in patients who are post RYGB provided the GJ anastomosis is of adequate diameter. Further studies are needed to evaluate the efficacy and safety, however potential now exists for therapeutic interventions in the defuntionalized stomach and duodenum, including ERCP.