Previous Gastric Bypass Surgery Research Articles

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

BackgroundMaternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.MethodsIn this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).ResultsThe women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030).ConclusionPost-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

(407) Buried Penis in Morbidly Obese Patient: Surgical Technique of Fat Pad Excision, Malleable Penile Prosthesis Insertion and Penile Split Skin Graft

Abstract Introduction Buried penis has a significant impact on quality of life affecting voiding and sexual function. Central and suprapubic deposition of adipose tissue related to obesity is a common cause. Objective This video shows the surgical approach of a complex case of buried penis managed with a suprapubic fat pad excision and simultaneous malleable penile prosthesis insertion. Methods We present a case of buried penis in a morbidly obese patient (BMI:43) with a history of two previous gastric bypass surgery and an apronectomy. affecting micturition and sexual function. A skin incision is made with a transverse incision at the level of the anterior superior iliac spine and a curvilinear inferior border. The apex of the inferior border should be approximately 2 finger breadth above the level of the penopubic junction. The incision is extended down to the rectus sheath and the spermatic cords at the lateral boundaries and the penile shaft at the midline are exposed. A malleable implant is inserted using the infrapubic approach and a split skin graft harvested to replace the unhealthy penile shaft skin. The dermis of the skin edges are secured to the rectus sheath with 0/0 vicryl sutures and the wound is closed in layers. Results Post-operative recovery was complicated by partial necrosis of the skin graft. At 3 months, the patient was able to stand to void and engage in sexual intercourse at 6 months. Conclusions The prevalence of obesity is increasing and in men, the presence of a suprapubic fat bad can result in a buried penis and affect voiding and sexual function. Although weight loss should be advised in the first instance, this may often not be enough. A combination of a suprapubic fat pad excision with malleable penile implantation and spit skin graft is a treatment option that can be considered. Disclosure No

Intralipid administration in case of a severe venlafaxine overdose in a patient with previous gastric bypass surgery

Intralipid administration in case of a severe venlafaxine overdose in a patient with previous gastric bypass surgery

Association of Previous Gastric Bypass Surgery and Patient Outcomes in Alcohol-Associated Cirrhosis Hospitalizations.

Roux-En-Y gastric bypass (RYGB) is associated with risk of alcohol use disorder. The impact of RYGB among patients with alcohol-associated liver disease (ALD) remains unknown. A retrospective cohort from National Inpatient Sample (01/2006-09/2015) database on 421,156 admissions with alcohol-associated cirrhosis (AC) was stratified for non-primary discharge diagnosis of previous RYGB. Admissions with RYGB (cases) were matched 1:3 to without RYGB (controls) based on propensity score on demographics, calendar year, socioeconomic status (insurance and zip code income quartile), obesity, diabetes, anxiety, and alcohol use disorder. Primary outcome was concomitant discharge diagnosis of alcoholic hepatitis (AH) or development of acute on chronic liver failure (ACLF). Of 10,168 admissions (mean age 49 yrs., 75% females, 79% whites), cases (N = 2542) vs. controls had higher prevalence of concomitant AH (18.8 vs. 17%, P = 0.032), hepatic encephalopathy (31 vs. 25%), infection (28 vs. 24%), and grade 3 ACLF (13 vs. 5%), P < 0.001. Conditional logistic regression models showed higher odds for AH, hepatic encephalopathy, and infection among cases. In-hospital mortality of 6.3% (43% in ACLF) was lower in cases, but similar in the sub-cohorts of AH (N = 1768) or ACLF (N = 768). Results were similar in a sensitivity analysis of matched cohort of 2016 hospitalizations (504 cases) with primary discharge diagnosis of AC. Among patients with AC, previous RYGB is associated with increased likelihood of concomitant AH, hepatic encephalopathy, and infection, but similar in-hospital mortality. Prospective studies are needed to validate, determine causality, and understand mechanisms of these findings among patients with alcohol-associated cirrhosis.

Follistatin secretion is enhanced by protein, but not glucose or fat ingestion, in obese persons independently of previous gastric bypass surgery.

Follistatin is secreted from the liver and is involved in the regulation of muscle mass and insulin sensitivity via inhibition of activin A in humans. The secretion of follistatin seems to be stimulated by glucagon and inhibited by insulin, but only limited knowledge on the postprandial regulation of follistatin exists. Moreover, results on postoperative changes after Roux-en-Y gastric bypass (RYGB) are conflicting with reports of increased, unaltered, and lowered fasting concentrations of follistatin. In this study, we investigated postprandial follistatin and activin A concentrations after intake of isocaloric amounts of protein, fat, or glucose in subjects with obesity with and without previous RYGB to explore the regulation of follistatin by the individual macronutrients. Protein intake enhanced follistatin concentrations similarly in the two groups, whereas glucose and fat ingestion did not change postprandial follistatin concentrations. Concentrations of activin A were lower after protein intake compared with glucose intake in RYGB. Glucagon concentrations were also particularly enhanced by protein intake and tended to correlate with follistatin in RYGB. In conclusion, we demonstrated that protein intake, but not glucose or fat, is a strong stimulus for follistatin secretion in subjects with obesity and that this regulation is maintained after RYGB surgery.NEW & NOTEWORTHY Circulating follistatin and activin A were studied after intake of isocaloric protein, fat, or glucose drinks in subjects with obesity with and without previous Roux-en-Y gastric bypass (RYGB). Protein intake enhanced follistatin similarly in both groups, whereas glucose and fat ingestion did not change follistatin. Activin A was lower after protein compared with glucose in RYGB. The novel finding is that protein intake, but neither glucose nor fat, stimulates follistatin secretion independently of previous RYGB.

Thyroidectomy in patients who have undergone gastric bypass surgery.

Morbid obesity is a chronic condition that may be challenging to treat. Gastric bypass surgery is used to treat morbid obesity and its complications. Hypocalcemia, a known complication after thyroidectomy, is usually transient and treatable. There is a growing body of literature indicating that patients with previous gastric bypass surgery are at an increased risk for recalcitrant, symptomatic hypocalcemia after thyroidectomy. The management of hypocalcemia in patients with prior gastric bypass surgery may be exceedingly difficult. Relevant articles published between 2008 and January 2017 were reviewed by topic. The review of literature was conducted using a systematic search of database resources, such as PubMed and EMBASE. Prior gastric bypass surgery may be an independent risk factor for developing profound hypocalcemia after thyroid surgery. Refractory hypocalcemia in patients who have undergone gastric bypass surgery is underreported. Careful consideration should be given to performing staged thyroidectomy and, in some cases, reversal of the bariatric surgery.

Hypoparathyroidism after total thyroidectomy in patients with previous gastric bypass

PurposeCase reports suggest that patients with previous gastric bypass have an increased risk of severe hypocalcemia after total thyroidectomy, but there are no population-based studies. The prevalence of gastric bypass before thyroidectomy and the risk of hypocalcemia after thyroidectomy in patients with previous gastric bypass were investigated.MethodsBy cross-linking The Scandinavian Quality Registry for Thyroid, Parathyroid and Adrenal Surgery with the Scandinavian Obesity Surgery Registry patients operated with total thyroidectomy without concurrent or previous surgery for hyperparathyroidism were identified and grouped according to previous gastric bypass. The risk of treatment with intravenous calcium during hospital stay, and with oral calcium and vitamin D at 6 weeks and 6 months postoperatively was calculated by using multiple logistic regression in the overall cohort and in a 1:1 nested case-control analysis.ResultsWe identified 6115 patients treated with total thyroidectomy. Out of these, 25 (0.4 %) had undergone previous gastric bypass surgery. In logistic regression, previous gastric bypass was not associated with treatment with i.v. calcium (OR 2.05, 95 % CI 0.48–8.74), or calcium and/or vitamin D at 6 weeks (1.14 (0.39–3.35), 1.31 (0.39–4.42)) or 6 months after total thyroidectomy (1.71 (0.40–7.32), 2.28 (0.53–9.75)). In the nested case-control analysis, rates of treatment for hypocalcemia were similar in patients with and without previous gastric bypass.ConclusionPrevious gastric bypass surgery was infrequent in patients undergoing total thyroidectomy and was not associated with an increased risk of postoperative hypocalcemia.

A5088 - Title: A Case Study: Management of a bile leak after partial cholecystectomy in a patient status post Roux-en-Y gastric bypass surgery with a controlled choledochocutaneous fistula

In this case we will discuss post operative management of a patient who underwent a partial cholecystectomy secondary to acute gangrenous cholecystitis. This case is complicated by the fact the patient had a previous history of gastric bypass surgery, limiting the options of treatment of cystic duct leak post operatively. We will discuss the details of our patient, the complications of his procedure and the means by which we manage a bile leak when previous gastric bypass surgery prevents treatment by conventional treatment pathways. There are very few cases such as this in literature today, which calls for further investigation and research.

Copper Deficiency (Hypocupremia) and Pancytopenia Late After Gastric Bypass Surgery

Hypocupremia, or copper deficiency, is a rare and underrecognized cause of bone marrow dysplasia. Most cases of copper deficiency in adults occurred historically in patients receiving total parenteral hyperalimentation or total parental nutrition. More recently, with the obesity epidemic and the prevalence of gastric bypass, cases of malabsorption-related copper deficiency have occurred. Copper deficiency can lead to significant cytopenias and possible neurologic sequelae, which can be misdiagnosed and mismanaged. Unfortunately, a delay in diagnosis and appropriate treatment may lead to permanent neurologic damage. We describe a woman with previous gastric bypass surgery who presented with pancytopenia and bone marrow biopsy findings consistent with a myelodysplastic syndrome with excess blasts. She was found to be significantly copper deficient. With replacement copper therapy, her cytopenias quickly resolved. We discuss the distinctive clinical and hematologic features of this rare cause of significant cytopenias and provide recommendations for monitoring and treatment of such patients. Moreover, this case is an important reminder that bariatric patients should have routine follow-ups after surgery and continue dietary supplements indefinitely.

Ketoacidosis with Unexpected Serum Isopropyl Alcohol

A 34-year-old woman presented to the emergency department with a chief complaint of acutely worsening abdominal pain. The patient reported the abdominal pain to be in the left lower quadrant and of several months' duration but noted that it had worsened substantially over the previous 10 days. She also reported diffuse muscle pain and nausea without emesis, no food intake over the previous 72 h, and only limited recent fluid intake consisting of ginger ale, water, Gatorade, and homemade liquor. Her last menstrual period was 2 weeks before admission. Her medical history was remarkable for posttraumatic stress disorder, bipolar disorder, gestational diabetes, a previous gastric bypass surgery, and an ambiguous history of “injury to the liver and pancreas.” She denied taking any medications or other illicit drugs, specifically denied “binge” drinking, and had recently received a tattoo from an unlicensed tattoo artist. She was homeless and resided in a tent city with her husband. The only remarkable findings of the physical examination were tachycardia and a mildly enlarged, nontender liver. She appeared ill and smelled of a campfire but was otherwise awake, alert, and cooperative. Selected laboratory results are shown in Table 1. Low urea nitrogen and albumin concentrations suggested probable malnutrition. The observed hypocalcemia of 7.4 mg/dL could be attributed only partly to the low albumin concentration, because the albumin-corrected total Ca concentration—which is equal to the measured total [Ca] + 0.8 mg/dL × (4.0 − [Albumin]), where [Ca] is the calcium concentration in milligrams per deciliter and [Albumin] is the albumin concentration in grams per deciliter (1)—was 8.8 mg/dL, less than the institutional lower reference limit. View this table: Table 1. Laboratory data.a Opiates and tricyclic antidepressants were identified in the patient's urine. The presence of opiates was not commented on in the medical record, so whether the clinical team was aware of this …

Retention of Capsule Endoscopes in a Patient after Roux-en-Y Gastric Bypass: A Case Report

Purpose: Video Capsule Endoscopy (VCE) is an important tool for minimally invasive evaluation of the small bowel (SB). Complication rates remain relatively low and few major contraindications have been identified. Currently the main complication of VCE is capsule retention, and retention at all levels of the gastrointestinal tract has been reported. Methods: Here we present the first case of capsule endoscope retention in a patient status post Roux-en-Y gastric bypass. Results: Case Presentation: A 50-year-old woman with a history of morbid obesity, status post Roux-en-Y gastric bypass, who presented to GI clinic for evaluation of iron deficiency anemia. Upper endoscopy and colonoscopy were performed without detection of significant pathological findings, and she was subsequently referred for VCE. The first study was incomplete as the capsule remained at the gastro-jejunal anastamosis. The patient underwent a repeat VCE procedure 2 weeks later. This study too was incomplete as the second capsule remained at the anastamotic site. Approximately 45 days post-procedure the patient successfully underwent upper endoscopy for retrieval of both capsule endoscopes. Upper endoscopic examination additionally showed a gastric pouch of about 4 to 5 cm, with significant narrowing of the outlet into the SB. The patient tolerated the procedure well without further complications. Conclusion: Video capsule endoscopy remains the preferred endoscopic imaging method of the SB with overall low complication rates. This case illustrates the importance of appropriate patient selection and evaluation of the functional patency of the gastrointestinal tract in patients with previous gastric bypass surgery. Utilization of radiographic imaging modalities such as SB follow-through to delineate the anatomy of the GI tract, or patency capsule to assess functional patency prior to VCE may be beneficial in this setting. Endoscopic deployment of the capsule endoscope should be more aggressively utilized in those patients with significant distal narrowing. Such interventions will become especially important in bariatric surgery patients as gastric bypass gains popularity among a growing population suffering from morbid obesity.

The impact of Roux‐en‐Y gastric bypass surgery for morbid obesity on second trimester obstetric ultrasound completion rates

Weight loss after bariatric surgery occurs by preferential loss of visceral and central body fat. We hypothesized that 2nd trimester sonographic completion rates would be higher among women with prior gastric bypass compared with women of similar body mass index without a prior gastric bypass. Women with gastric bypass undergoing 2(nd) trimester sonographic examination were matched 1:1 with controls for body mass index and prior cesarean section. The primary outcome was completion of the fetal anatomic evaluation according to American Institute of Ultrasound in Medicine guidelines. Initial sonogram completion rates for cases, 28/40 (70%), and controls (30/40, 75%) were similar (p = 0.62). Completion rates for women returning for follow-up were 100% in both groups. Overall completing rates were identical for cases (37/40, 92.5%) and controls (37/40, 92.5%). Previous gastric bypass surgery does not affect 2nd trimester sonographic completion rates.

A Large Reaccumulating Cystic Lesion in a Gastric Bypass Patient

Purpose: A 42 yo AAF with HTn, bipolar disorder, chronic ethanol abuse, breast reduction 6y ago and gastric bypass 4y ago came with abdominal pain and an epigastric lump. A CT scan showed a large multiloculated cystic collection anterior to pancreas extending up to the pelvis. It was assessed as a pancreatic pseudocyst secondary to ethanolinduced pancreatitis. She was treated with bowel rest, TPN and octreotide. When no regression observed after 3 weeks a CT guided catheter drainage was performed. The drainage was persistently high around 1.5 litres/day with high levels of amylase and lipase in fluid analysis. The collection resolved after a few days but recurred after catheter dislodgment. The patient began complaining of abdominal discomfort. ERCP was technically infeasible because of previous gastric bypass surgery. She was transferred to a tertiary care facility where a repeat CT scan was interpreted as obstruction and distention of excluded stomach/duodenal limb from the previous gastric bypass surgery. Upon exploratory laparotomy the biliopancreatic limb was was found incarcerated and atretic through the Peterson's space. Resection and anastomosis was performed and a gastrostomy tube was placed. The postop period was uneventful. The gastrostomy tube was removed after 4 days. Her symptoms resolved completely, she was discharged on regular diet. No recurrences were reported till 6 mo in follow ups. Internal hernias have been reported in 0.2-9% of gastric bypass patients. (1) Petersen's type is one of the rarest type which occurs through the potential gap between the jejunal mesentery and mesocolon behind the alimentary limb. (2) With the growing number of bariatric surgeries nowadays, awareness of such a complication is pertinent to avoid misdiagnosis and delay in definitive surgical management as happened in this case. Bibliography: 1. Filip JE, et al. Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Am Surg 2002; 68:640-3. 2. Patel RY, et al. Internal hernia complications of gastric bypass surgery in the acute setting: spectrum of imaging findings. Emerg Radiol. DOI 10.1007/s10140-008-0781-7.Figure: Petersen's space.

Dumping Syndrome: Establishing Criteria for Diagnosis and Identifying New Etiologies

To investigate the current incidence and identify the current etiologies of rapid gastric emptying (dumping syndrome) in patients with a spectrum of gastrointestinal symptoms, including nausea, vomiting, abdominal pain, or diarrhea. The results for a 4-h radionuclide gastric emptying test (GET) using a standardized scintigraphic technique were reviewed in 545 patients to see which patients met criteria for rapid gastric emptying, defined as >50% emptying of isotope-labeled solid meal at 1 h. Forty-eight of 545 (8.8%) patients (28 females, mean age 46 +/- 2 years, range 32-58 years) had rapid GET. Seventeen of 59 (35%) met Rome III diagnostic criteria for cyclic vomiting syndrome (CVS). Twelve of these 59 (25%) patients were regarded as non-ulcer dyspepsia and six (13%) had dyspepsia in the setting of diabetes mellitus. Five (10.5%) were post-fundoplication surgery, where an accidental vagotomy was confirmed by sham meal challenge; previous gastric bypass surgery for obesity had been performed in three (6%) patients. Five (10.5%) patients with unexplained abdominal pain and diarrhea had the working diagnosis of irritable bowel syndrome. Rapid gastric emptying can be identified in a sizeable subset (9%) of patients with unexplained nausea, vomiting, abdominal pain, and diarrhea when criteria are applied to the standardized scintigraphic gastric emptying meal.

Authors’ response

We read with interest the letter by Decock et al regarding the rare congenital ocular malformation (orbital cyst and bilateral colobomatous microphthalmos).1 The female child reported was the product of...

Obese and Nonobese Patients

We analyzed 80 patients who underwent abdominoplasty at the University of Tor Vergata "Policlinico Casilino", Rome to determine the effect of obesity on the incidence of complications after this surgery. The study patients were divided into 3 groups, obese, overweight, and normal weight, based on the degree to which their preoperative weights varied from their ideal body weight. A history of previous bariatric surgery was also analyzed to determine what impact that might have on subsequent abdominoplasty. Results showed that the records of 80 patients who underwent an abdominoplasty at University of Tor Vergata Policlinico indicated that 76% of obese patients had complications compared with the overweight and normal-weight patients, who had complication rates of 35% and 33%, respectively. Previous gastric bypass surgery had no significant effect on the incidence of postabdominoplasty complications. Based on these findings, the authors conclude that obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight-reduction surgery.

Metabolic Bone Disease after Gastric Bypass Surgery for Obesity

The popularity of gastric bypass surgery for treatment of morbid obesity has been increasing in recent years. Osteomalacia and osteoporosis are commonly observed in patients who have had partial gastric resections for treatment of peptic ulcer disease. Recently, we encountered four patients with previous gastric bypass surgery who had metabolic bone disease similar to that reported in the older literature in patients who had partial gastrectomies. Review of clinical data of four patients who developed osteomalacia and osteoporosis 9 to 12 years after gastric bypass surgery for morbid obesity. All subjects were women, 43 to 58 years old. Three had Roux-en-Y gastric bypass, and the other had a biliopancreatic diversion 9 to 12 years prior to presentation. Weight loss averaged 41.8 kg. Patients reported fatigue, myalgias, and arthralgias. They had symptoms for many months or years before the correct diagnosis was established. All were osteopenic or osteoporotic with hypocalcemia, very low or undetectable 25-hydroxyvitamin D levels, secondary hyperparathyroidism, increased 1,25-dihydroxyvitamin D levels, and increased serum alkaline phosphatase. Relatively little has been published in the general medical literature about this postoperative complication of bariatric surgery. Yet, nearly all patients after bariatric surgery will receive their long-term follow-up from a primary care physician. Physicians and patients need to be aware of this complication and take measures to identify and prevent it.

Wound complications of abdominoplasty in obese patients.

The records of 90 patients who underwent an abdominoplasty at the University of Virginia Health Sciences Center were analyzed to determine the effect of obesity on the incidence of complications after this surgery. The study patients were divided into three groups-obese, borderline, and nonobese-based on the degree to which their preoperative weights varied from their ideal body weight. A history of previous bariatric surgery was also analyzed to determine what impact that might have on subsequent abdominoplasty. Results showed that 80% of obese patients had complications compared with the borderline and nonobese patients, who had complication rates of 33% and 32.5% respectively (p = 0.001). Previous gastric bypass surgery had no significant effect on the incidence of postabdominoplasty complications. Based on these findings the authors conclude that obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight reduction surgery.