Open Roux-en-Y Gastric Bypass Research Articles

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss.

Gastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS). The primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision. Single Academic Institution, Center of Bariatric Excellence. We selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients' demographics, perioperative outcomes, and TBWL were analyzed. One hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time. Our results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.

Prevalence of Rhabdomyolysis Following Bariatric Surgery and its Associated Risk Factors: a Meta-Analysis.

This study aimed to evaluate the prevalence of rhabdomyolysis (RML) following bariatric surgery and potential associated factors. We systematically searched PubMed, Embase, and CENTRAL for relevant trials from database inception through August 2022. Articles were eligible for inclusion if they reported the prevalence of RML after bariatric surgery and provided at least one of the following outcome indicators: preoperative mean BMI/mean operative time for the included population. Sixteen studies with a total of 1540 patients were analyzed. The mean preoperative age distribution of the included patients was centered between 32.9 and 47.0years, and the mean preoperative BMI ranged from 42.3 to 60.0kg/m2. The operative time varied between 126.7 and 403.3min. The overall pooled crude prevalence of post-bariatric surgery RML was 19.4%. Subgroup analyses showed the pooled prevalence of RML was 8.1% for operative duration > 120 and ≤ 180min, 32.8% for > 180 and ≤ 240min, and 47.4% for > 240min. Meta-regression revealed that operation time was an independent risk factor for developing RML. Besides, BMI > 50kg/m2 and open Roux-en-Y gastric bypass (RYGB) indicated a higher risk of RML. Post-bariatric surgery RML prevalence occurred more frequently with the extension of the operation time. For bariatric subjects with surgery time > 180min, open RYGB, or BMI > 50kg/m2, CKP could be routinely measured early to verify the presence of RML and to actively prevent its fatal complications.

A rare long-term complication in a patient with gastric bypass: remnant gastric perforation

Roux-en-Y gastric bypass (RYGB), one of the most frequently performed operations within the scope of bariatric surgery, creates a remnant stomach containing the fundus, corpus and antrum where gastric acid and pepsinogen are synthesized in significant amounts. Although rare complications such as bleeding, perforation and ischemia occur regarding the remnant stomach. A 47-year-old male patient who was operated on for open RYGB 10 years ago was admitted to the emergency department with complaints of abdominal pain and deterioration in his general condition. The patient who had widespread tenderness in the abdomen was unstable on physical examination. It was observed that the remnant stomach was perforated 2.2 cm from the anterior surface of the corpus at emergency laparotomy after defining the upper gastrointestinal anatomy with the aid of peroperative endoscopy. The patient whose remnant stomach was resected was discharged uneventfully on the 5th postoperative day. The approach to remnant gastric perforations due to benign causes is the same as for gastric perforations. Laparotomy is indicated in unstable patients.

Combination anti-obesity medications to effectively treat bariatric surgery weight regain at an academic obesity center.

Combination anti-obesity medications (AOMs) to treat postoperative bariatric surgery weight regain have limited data on their use in the clinical setting. Understanding the optimal treatment protocol in this cohort will maximize weight loss outcomes. A retrospective review of bariatric surgery patients (N=44) presenting with weight regain at a single academic multidisciplinary obesity center who were prescribed AOM(s) plus intensive lifestyle modification for 12months. Age: 28-76years old, 93% female, mean weight 110.2±20.3kg, BMI 39.7±7.4kg/m2, presenting 5.2±1.6years post-bariatric surgery [27 (61.4%), 14 (31.8%), and 3 (6.8%) laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic vertical sleeve gastrectomy (VSG), and open RYGB, respectively], with 15.1±11.1kg mean weight gain from nadir. Mean weight loss after medical intervention at 3-, 6-, and 12-month time points was 4.4±4.6kg, 7.3±7.0kg, and 10.7±9.2kg, respectively. At 12months, individuals prescribed 3 or more AOMs lost more weight than those prescribed one (-14.5±9.0kg vs. -4.9±5.7kg, p<0.05) irrespective of age, gender, number of comorbidities, initial weight or BMI, type of surgery, or GLP1 use. RYGB patients lost less weight overall (7.4% vs. 14.8% VSG respectively; p<0.05). Combination AOMs may be needed to achieve optimal weight loss results to treat post-operative weight regain.

A novel approach for weight regain after Roux-en-Y gastric bypass: Staged transoral outlet reduction (TORe) followed by surgical type 1 distalization.

Video 1Transoral outlet reduction.Video2. Laparoscopic type 1 distalization of the Roux limb.

Pre-operative direct and inverse clinical characteristic variations by age do not resolve up to 24 months following open roux-en-y gastric bypass

Background: Today open Roux-en-Y gastric bypass (ORYGB) is reserved for abdomens too complex or obesity too severe for laparoscopic surgery. However, outcomes by age in ORYGB are unknown. Objective: Identify variation by age in ORYGB patients. Setting: Independent database. Methods: 5389 ORYGB BOLD patients was analyzed retrospectively by age: &lt;30 (591), 30-40 (1252), 40-50 (1527), 50-60 (1388), 60-70 (592) and &gt;70 (39). Statistics: ANOVA/general linear model. Results: Baseline female/male (p&lt;0.01), weight, BMI, African-American, Hispanic, Medicaid, Private insurance, self-pay (p&lt;0.0001), PCOS, PTC (n=10) varied inversely with age. Medicare, CHF, HTN, angina, LEE, PVD, IHD, dyslipidemia, OHS, diabetes, gout, IFS, and unemployment varied directly. Caucasian, Asian, Other race, DVT/PE, hernia, cholelithiasis, GERD, panniculitis, liver disease, SUI, MSP, fibromyalgia, alcohol and tobacco abuse, depression, PI, MHD (n=17) vary non-linearly. At 12 months, in spite of equal BMI by age, CHF, HTN, angina, PVD, dyslipidemia, cholelithiasis, SUI, diabetes, gout, IFS (n=10) varied directly. PCOS and PTC varied inversely, and LEE, OSA, hernia, MSP, tobacco abuse, depression, MHD varied non-linearly. 24 months CHF, HTN, angina, dyslipidemia, diabetes, IFS, and MSP vary directly. PTC and tobacco abuse varied inversely. LEE, OSA, PHTN, hernia, PCOS, and tobacco abuse varied non-linearly. Conclusions: ORYGB patients vary dramatically by decade of age. Pre-operatively 10 co-morbidities varied inversely, 13 directly, and 17 non-linearly by age. In spite of equal BMI by age at 24 months, important co-morbidities CHF, HTN, angina, dyslipidemia, diabetes varied directly, tobacco inversely, and OSA non-linearly. This advance clinical knowledge of age variation can aid ORYGB management

Asymptomatic Cholelithiasis and Bariatric Surgery: a Comprehensive Long-Term Analysis of the Risks of Biliary Disease in Patients Undergoing Primary Roux-en-Y Gastric Bypass.

Currently, there is little consensus on management of the in situ gallbladder of patients undergoing gastric bypass. Our aim was to evaluate outcomes of selective concomitant cholecystectomy (CCY) and long-term biliary outcomes after Roux-en-Y gastric bypass (RYGB). We performed a retrospective analysis of patients undergoing laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi-square, Fisher's exact, or Wilcoxon rank-sum tests were used to compare outcomes. Concomitant CCY was performed on a selective basis. Three thousand and four patients underwent a RYGB (LRYGB n = 2458, open RYGB n = 546). Fifty-two percent (n = 1670) of patients had undergone CCY at any stage. Thirty-one percent of patients (n = 933) had CCY prior to RYGB, 13% (n = 403) had a concomitant CCY and 13% (n = 214) of the remainder required interval CCY. In the LRYGB subgroup, 29.9% (n = 735) had a prior CCY; 12.9% (n = 202) of those with an in situ gallbladder required interval CCY. Those who underwent concomitant CCY/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concomitant CCY group was significantly older and had higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity Index, and a higher medication count. There was no significant difference in BMI nadir, length of stay, complications, or mortality. Interval CCY had a higher incidence of CCY-related complications. Our study suggests a higher percentage of bariatric patients with in situ gallbladders will undergo interval CCY than documented in recently published guidelines. Concomitant CCY can be performed without an increase in length of stay or complications. Interval CCY may be associated with a higher complication rate.

A381 Clinical Characteristics and Outcomes Vary by Sex in Open Roux-en-Y Gastric Bypass

[SG1] : Today, open Roux-en-Y gastric bypass (ORYGB) is reserved for patients too obese for laparoscopic RYGB or with intra-abdominal scarring. Every clinical insight helps with these fragile individuals. Variation pre-operative and in outcomes by sex in ORYGB is unknown. Objective: Identify variation by sex in clinical characteristics and outcomes of ORYGB.

Cholecystectomy after gastric bypass—incidence and complications

BackgroundAlthough cholecystectomy incidence is known to be high after Roux-en-Y gastric bypass (RYGB) surgery, the actual increase in incidence is not known. Furthermore, the outcome of cholecystectomy after RYGB is not known. ObjectivesTo estimate cholecystectomy incidence before and after RYGB and to compare the outcome of post-RYGB cholecystectomy with the cholecystectomy outcome in the background population. SettingNationwide Swedish multiregister study. MethodsThe Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (n = 79,386) and the Scandinavian Obesity Surgery Registry (n = 36,098) were cross-matched for the years 2007 through 2013 and compared with the National Patient Register. ResultsThe standardized incidence ratio for cholecystectomy before RYGB was 3.42 (2.75–4.26, P<.001); the ratio peaked at 11.4 (10.2–12.6, P<.001) 6–12 months after RYGB, which was 3.54 times the baseline level (2.78–4.49, P<.001). After 36 months, the incidence ratio had returned to baseline. The post-RYGB group demonstrated an increased risk of 30-day postoperative complications after cholecystectomy (odds ratio 2.13, 1.78–2.56; P<.001), including reoperation (odds ratio 3.84, 2.76–5.36; P<.001), compared with the background population. The post-RYGB group also demonstrated a higher risk of conversion, acute cholecystectomy, and complicated gallstone disease and a slightly prolonged operative time, adjusted for age, sex, American Society of Anesthesiologists class, and previous open RYGB. ConclusionCompared with the background population, the incidence of cholecystectomy was substantially elevated already before RYGB and increased further 6–36 months after RYGB. Previous RYGB doubled the risk of postoperative complications after cholecystectomy and almost quadrupled the risk of reoperation, even when intraoperative cholangiography was normal.

Prevalence of Vitamin and Mineral Deficiencies in Bariatric Patients Following the 2013 Updated Supplementation Guidelines

BackgroundBariatric surgery is the most effective obesity treatment. However, patients undergoing bariatric surgery are high‐risk for nutritional deficiencies, especially post‐operatively. In March 2013, the American Society for Metabolic and Bariatric Surgery (ASMBS) released updated nutritional supplementation guidelines with the goal of improving nutritional deficiencies following bariatric surgery.ObjectiveTo investigate the ability of the 2013 ASMBS standardized supplementation to adequately treat patients after bariatric surgery, including differences by procedure type and in fat and water soluble vitamins.MethodsWe retrospectively collected data on 105 patients undergoing Roux‐en‐y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) using electronic medical records from February 2015 to September 2013, when the recommendations were implemented at our center. Labs were collected at 3 months, 6 months, and 1 year post‐operatively. Nutrition labs included fat soluble vitamins A, D, and E‐α; water soluble vitamins B1 (thiamine), folate, and B12; and iron studies. Other markers of malnutrition included albumin, prealbumin, and parathyroid hormone. Both clinical and frank deficiencies were examined. Univariate analysis was used to test for significant differences by procedure. Quantitative variables were analyzed as means with 95% confidence intervals, setting α=0.05.ResultsFifty‐eight of the 173 patients examined were excluded due to missing nutrition labs. Of the 105 patients included, 34 (32.4%) underwent laparoscopic RYGB, 6 (5.7%) underwent open RYGB, 63 (60.0%) underwent laparoscopic VSG, and 2 (1.9%) underwent open VSG. We had follow up data for 81 (77.1%) at 3 months, 49 (46.7%) at 6 months, 58 (55.2%) at 1 year. Clinical and frank deficiencies were found in 74.3% and 34.3% of patients, respectively, most commonly in vitamin D, iron, and vitamin B1. Fat soluble deficiencies consistently occurred at twice the rate of water soluble. Patients undergoing RYGB or VSG were generally similar, differing significantly by diabetes, length of stay post‐operatively, and surgical approach (open or robotic). We found a general trend of more deficiencies following RYGB, with TIBC at 3 months, vitamin D at 6 months, and iron at 3 months and 1 year reaching statistical significance. The highest prevalence of deficiencies was seen at 6 months, immediately following the greatest weight loss (from 3 to 6 months).ConclusionsWe found an alarming 74.3% of patients in this cohort to have nutritional deficiencies following bariatric surgery despite the publication of the ASMBS supplemental guidelines. Furthermore, RYGB was associated with more nutrient deficiencies, more open surgeries, and longer length of stay. Patient follow up is of concern and may be indicative of poor adherence to the medical regimen. While further investigations may be warranted to improve supplementation guidelines, non‐compliance may account for some of the nutritional deficiencies. Supplementation guidelines are necessary; however, they are only effective if patients adhere to them. Further studies should investigate reasons for poor follow‐up in the bariatric surgical population and interventions that may improve adherence.

Anastomotic techniques in open Roux-en-Y gastric bypass: primary open surgery and converted procedures

BackgroundOpen Roux-en-Y gastric bypass (RYGB) may be chosen because of known widespread adhesions or as a result of conversion during laparoscopic surgery. Although conversions are rare, they occur even in experienced hands. The gastrojejunostomy may be performed with a circular stapler (CS) or a linear stapler (LS) or may be entirely hand sewn (HS). Our aim was to study differences in outcomes regarding the anastomotic techniques utilized in open surgery. SettingNationwide cohort. MethodsData on open surgery, both primary open and converted procedures from Scandinavian Obesity Surgery Registry were analyzed for the years 2007–2013. Outcomes were assessed through multivariate analysis, adjusting for gender, age, preoperative body mass index, diabetes, conversion, and technique used for the gastrojejunostomy. ResultsCS was the most common method used for primary open RYGB (58%), whereas LS was the most common for converted RYGB (63%). HS was uncommon in both groups. Operative time was shorter for LS than for CS in the primary open RYGB (110±40 min versus 132±46 min; P<.001). Anastomotic leakage rates were similar in primary open RYGB (1.0%–2.4%), but leakage rates for LS in converted procedures was 10.1%, thus higher compared with 2.1% in converted CS patients (P = .02). Odds ratio for leakage was 2.87 (95% confidence interval 1.18–6.97) for LS using CS as a reference when adjusting for variables above. ConclusionLS was associated to increased risk of leakage in patients with conversion from laparoscopic RYGB to open RYGB. Conversion to open surgery was associated to increased risk of leakage. Technique used for the gastrojejunostomy did not affect weight loss.

Quality and safety in obesity surgery—15 years of Roux-en-Y gastric bypass outcomes from a longitudinal database

BackgroundMost population-based studies lack long-term data, making the reporting of true mortality and outcome rates difficult. An accurate estimate of these rates in a high-risk population is critical for obtaining informed consent, especially for an elective procedure such as Roux-en-Y gastric bypass (RYGB). ObjectivesTo examine the longitudinal outcomes of RYGB. SettingThe California Office of Statewide Health Planning and Development (OSHPD) longitudinal database. MethodsThe OSHPD longitudinal database was queried for patients who underwent RYGB between 1995 and 2009. The primary outcome was mortality rates at 1, 5, and 10 years. Secondary outcomes were marginal ulcer and reoperation. The Cox hazard proportional analysis was used to determine adjusted survival and long-term outcomes for laparoscopic RYGB compared with open RYGB. ResultsThe study included 129,432 RYGB patients. Rates of laparoscopy increased from 3% to 35% from 1995 to 2004 and then steeply increased to 80% in 2005 and to 93% in 2009. Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%, respectively; the rates of marginal ulcer were .3%, .7%, and 1%, respectively; and the reoperation rates were .3%, .8%, and 1.2%, respectively. Predictors of poor outcomes were male gender, age, smoking, alcohol, Medicare, Medi-Cal insurance, and Asian or Native American race. The laparoscopic approach was protective against death (hazard ratio [HR] 95% confidence interval [95%CI]: .63[.58–.69]) and long-term complications (HR .78[.72–.85]). ConclusionsThis longitudinal population study showed high rates of mortality following RYGB, with improved long-term outcomes when the laparoscopic approach was used.

Definitive surgical management of staple line leak after sleeve gastrectomy

BackgroundSleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature. ObjectivesThis study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results. SettingSingle surgeon experience based at a tertiary university hospital in Beirut, Lebanon. MethodsRetrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013. ResultsTen patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m2, respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13–39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1–7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m2 versus 30 kg/m2) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5–55.9 mo) with an average percentage excess weight loss of 74% (57%–120%). ConclusionsDefinitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.

Surgical management of gastrogastric fistula

BackgroundGastrogastric fistula (GGF) is a rare complication after Roux-en-Y gastric bypass (RYGB) that can be challenging to treat. ObjectiveThe aim of this study is to examine our surgical experience in the management of GGF after RYGB. SettingAcademic center, United States. MethodsWe report a consecutive series of 36 patients who underwent surgery for GGF at our institution between 2005 and 2013. ResultsThe cohort had a mean age of 48.0±10.8 years, mean body mass index (BMI) of 34.6±11.3 kg/m2, and an average number of 5.0±2.0 co-morbidities at the time of GGF revision. Of the 36 patients, 16 (44.4%) had previous open RYGB. Endoscopy confirmed GGF in 26 patients (72.2%), whereas upper gastrointestinal (GI) series indicated GGF in 21 of 30 cases (70.0%). The GGF surgery was on average 6.4±3.8 years after the primary procedure. All patients underwent surgical management either in the form of a redo gastrojejunal anastomosis with excision of fistula (77.7%) or a remnant gastrectomy with excision of fistula (22.2%). Mean operative time, blood loss, and length of stay were 248.4±103.3 minutes, 232.7±270.2 mL, and 8.5±8.6 days, respectively. One major intraoperative and 6 early postoperative complications occurred. After a mean follow-up of 38.4±30.0 months, the mean BMI was 35.5±6.2 kg/m2 in patients with weight regain before GGF revision (P<.05) versus 25.0±6.1 kg/m2 in patients without weight regain (P = .7). ConclusionGGF is a rare complication of RYGB. Surgical treatment should be tailored to the presenting symptoms and associated anatomic abnormality. Anastomotic revisions are associated with higher complication rates.

Predictors of Hospital Readmission after Bariatric Surgery

Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, surgical variables, and postoperative complications associated with readmission. Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors. There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%. Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.

Differences in open versus laparoscopic gastric bypass mortality risk using the Obesity Surgery Mortality Risk Score (OS-MRS)

BackgroundThe Obesity Surgery Mortality Risk Score (OS-MRS) was developed to ascertain preoperative mortality risk of patients having bariatric surgery. To date there has not been a comparison between open and laparoscopic operations using the OS-MRS. ObjectiveTo determine whether there are differences in mortality risk between open and laparoscopic Roux-en-Y Gastric Bypass (RYGB) using the OS-MRS. SettingThree university-affiliated hospitals. MethodsThe 90-day mortality of 2467 consecutive patients who had primary open (1574) or laparoscopic (893) RYGB performed by one surgeon was determined. Univariate and multivariate analysis using 5 OS-MRS risk factors including body mass index (BMI) gender, age>45, presence of hypertension and preoperative deep vein thrombosis (DVT) risk was performed in each group. Each patient was placed in 1 of 3 OS-MRS risk classes based on the number of risks: A (0–1), B (2–3), and C (4–5). ResultsPreoperative BMI and DVT risk factors were significantly greater in the open group (OG). Preoperative age was significantly greater in the laparoscopic group (LG). There were significantly more class B and C patients in LG. Ninety-day mortality rates for OG and LG patients were 1.0% and .9%, respectively. Pulmonary embolism was the most common cause of death. All deaths in LG occurred during first 4 years of that experience. Mortality rate by class was A = .1%; B = 1.5%; C = 2.3%. The difference in mortality between class B and C patients was not significant. Univariate analysis in the OG indicated that BMI, age, gender, and DVT risk were significant predictors of mortality. In the LG only BMI and DVT were significant predictors of death. Presence of hypertension was not a significant predictor in either group. Multivariate analysis excluding hypertension found that age was predictive of mortality in the OG while BMI (P = .057) and gender (P = .065) approached statistical significance. Conversely, only BMI was predictive of mortality in the LG with age approaching significance (P = .058). In multivariate analysis DVT risk was not predictive of mortality in either group. ConclusionsThere are significant differences in the predictive value of the OS-MRS between open and laparoscopic RYGB. Although laparoscopic patients were significantly older versus the open patients, age was not predictive of mortality after laparoscopic RYGB. BMI trended toward increased mortality risk in both groups. Changes in technique and protocol likely contributed toward no mortality during the last 6 years of our laparoscopic experience.

A prospective, randomized, multicenter trial of Surgisis Gold, a biologic prosthetic, as a sublay reinforcement of the fascial closure after open bariatric surgery

This prospective, multicenter, randomized clinical trial was performed to compare the effectiveness of the bioprosthesis Surgisis Gold (Cook Biotech, Inc, West Lafayette, IN) to suture closure alone in reinforcing the abdominal wall after open Roux-en-Y gastric bypass (RYGB). A total of 402 adult patients (body mass index ≥35kg/m(2)) scheduled to undergo open RYGB procedures were randomized to receive either Surgisis Gold placed as a sublay directly under and opposed to the posterior rectus fascia without intervening preperitoneal fat or suture closure alone. Peri- and postoperative complications were tracked. Incisional hernia formation in each group was examined at 6weeks, 3, 6, and 9months, and 1 and 2years after RYGB. A total of 380 (78 male; 302 female) patients with a mean age of 45years (range 18-69) and a mean BMI of 48 (range 35-79) underwent RYGB. There were no differences in patient demographics or comorbidities between groups. Placement of the Surgisis Gold increased operating time by an average of 14minutes. Complications were more common in the Surgisis Gold group with significantly more wound events and seroma formation compared with the suture closure alone group. At final follow-up, 32 of 185 (17%) of patients in the reinforced arm and 38 of 195 (20%) in the suture alone arm developed an incisional hernia (P=.6). In this challenging patient population, the use of Surgisis Gold for reinforcing the abdominal wall after open RYGB was not shown to be greatly different from a primary suture repair.

Metabolic Syndrome Prevalence and Associations in a Bariatric Surgery Cohort from the Longitudinal Assessment of Bariatric Surgery-2 Study

Metabolic syndrome is associated with higher risk for cardiovascular disease, sleep apnea, and nonalcoholic steatohepatitis, all common conditions in patients referred for bariatric surgery, and it may predict early postoperative complications. The objective of this study was to determine the prevalence of metabolic syndrome, defined using updated National Cholesterol Education Program criteria, in adults undergoing bariatric surgery and compare the prevalence of baseline co-morbid conditions and select operative and 30-day postoperative outcomes by metabolic syndrome status. Complete metabolic syndrome data were available for 2275 of 2458 participants enrolled in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2), an observational cohort study designed to evaluate long-term safety and efficacy of bariatric surgery in obese adults. The prevalence of metabolic syndrome was 79.9%. Compared to those without metabolic syndrome, those with metabolic syndrome were significantly more likely to be men, to have a higher prevalence of diabetes and prior cardiac events, to have enlarged livers and higher median levels of liver enzymes, a history of sleep apnea, and a longer length of stay after surgery following laparoscopic Roux-en-Y gastric bypass (RYGB) and gastric sleeves but not open RYGB or laparoscopic adjustable gastric banding. Metabolic syndrome status was not significantly related to duration of surgery or rates of composite end points of intraoperative events and 30-day major adverse surgical outcomes. Nearly four in five participants undergoing bariatric surgery presented with metabolic syndrome. Establishing a diagnosis of metabolic syndrome in bariatric surgery patients may identify a high-risk patient profile, but does not in itself confer a higher risk for short-term adverse postsurgery outcomes.

Concomitant bariatric and ventral/incisional hernia surgery in morbidly obese patients

Ventral hernias are not uncommon in the bariatric population. Their management is technically demanding and remains controversial. Hernia complications can be lethal after bariatric surgery (BS). We herein report our experience with concomitant BS and ventral hernia repair (VHR). We performed a retrospective analysis of a prospectively maintained database queried for combined procedures. Hernias were repaired after complete reduction (when the defect was not empty) using a dual mesh fixed to the abdominal wall with absorbable tackers. Data collected included demographics, anthropometrics, co-morbidities, peri-operative course, and intermediate weight loss and co-morbidity status. Between 2007 and 2012, a total of 54 patients (34 females, mean body mass index 44.2 kg/m(2)) underwent concomitant BS and VHR. The vast majority of procedures were laparoscopic sleeve gastrectomies (N = 48; 89 %). Others included laparoscopic Roux-en-y gastric bypass (RYGB), open RYGB, and laparoscopic gastric banding (two each). Six patients had complications (11 %): three leaks, two abdominal wall hematomas, and one pulmonary embolism. Hernia recurrence was noted in one patient (1.8 %). Average excess weight loss post-surgery was 49.9 ± 10.3 and 57.7 ± 9.2 % at 6 and 12 months, respectively. The total number of pre-operative co-morbidities was 110. At 12-month follow-up, 50 % (N = 56) were completely resolved and 38 % (N = 42) were improved. Concomitant BS and VHR is feasible and safe, obviating the need for two separate procedures while not hampering the outcome of either. Complication rates for the combined surgery do not seem to be adversely affected.

Cost-effectiveness of bariatric surgical procedures for the treatment of severe obesity

One-third of Americans are obese and an increasing number opt for bariatric surgery. This study estimates the cost-effectiveness of common bariatric surgical procedures from a healthcare system perspective. We evaluated the three most common bariatric surgical procedures in the US: laparoscopic gastric bypass (LRYGB), conventional (open) Roux-en-Y gastric bypass (ORYGB), and laparoscopic adjustable gastric banding (LAGB) compared to no surgery. The reference case was defined as a 53-year old female with body mass index (BMI) of 44 kg/m(2). We developed a two-part model using a deterministic approach for the first 5-year period post-surgery and separate empirical forecasts for the natural history of BMI, costs and outcomes in the remaining years. We used a combination of datasets including Medicare and MarketScan(®) together with estimates from the literature to populate the model. Bariatric surgery produced additional life expectancy (80-81 years) compared to no surgery (78 years). The incremental cost-effectiveness ratios (ICERs) of the surgical procedures were US $6,600 per quality-adjusted life expectancy (QALY) gained for LRYGB, US $6,200 for LAGB, and US $17,300 for ORYGB (3 % discount rate for cost and QALYs). ICERs varied according to choice of BMI forecasting method and clinically plausible variation in parameter estimates. In most scenarios, the ICER did not exceed a threshold of US $50,000 per QALY gained.