Previous Roux-en-Y Gastric Bypass Research Articles

Hiatal hernia repair after previous laparoscopic Roux-en-Y gastric bypass

BackgroundSymptomatic hiatal hernia (HH) with pouch migration after previous laparoscopic Roux-en-Y gastric bypass (RYGB) is an uncommon complication, with limited extant evidence for the utility of surgical repair. ObjectiveTo evaluate the presentation and resolution of symptoms in patients with HH repair after previous RYGB. SettingMulticenter University Hospital. MethodsA retrospective review was conducted from 2010 to 2022. Patients with prior RYGB who were undergoing subsequent isolated HH repair were included. Patients undergoing incidental HH repair during concomitant revisional bariatric surgery were excluded. Baseline characteristics and surgical outcomes were evaluated and presented as medians (25th–75th percentile). ResultsForty-four patients met the inclusion criteria. The time from RYGB to HH repair was 59 months (39–88). Body mass index at HH repair was 31 kg/m2 (27–39). The most common presenting symptoms of hernia were dysphagia (52%), gastric reflux (39%), and abdominal pain (36%). All HH repairs were completed with a minimally invasive approach (98% laparoscopic, 2% robotic). Nonabsorbable suture was used in 98% of patients, with bioabsorbable mesh in 30%. At a median 28-day (12–117) follow-up, 70% of patients reported full symptom resolution and 23% partial resolution. At follow-up, 2 patients had radiologic HH recurrence, with 1 requiring reoperation. ConclusionsThis is the largest series of isolated HH repair for symptomatic pouch migration after previous RYGB. Common presenting symptoms are dysphagia and reflux, and surgical repair yields a high rate of symptom resolution in the short term. Longer follow-up is needed to evaluate the durability of this intervention.

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass.

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established. To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients. Swedish nationwide multi-registry study. The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and2020. Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3-52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001). LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.

Postprandial secretion of follistatin after gastric bypass surgery and sleeve gastrectomy

Follistatin is secreted from the liver and may regulate muscle growth and insulin sensitivity. Protein intake stimulates follistatin secretion, which may be mediated by increased glucagon in the context of low insulin concentrations. We investigated circulating follistatin after mixed-meals in two cohorts of patients who were part of previously published studies and had undergone bariatric surgery with either simultaneous assessment of amino acid absorption or administration of the GLP-1 receptor antagonist exendin-(9−39), which increased glucagon concentrations and impaired insulin secretion. Study 1 comprised obese matched subjects with previous Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery and unoperated controls who underwent 6-hour mixed-meal tests with intravenous and oral tracers including intrinsically labelled caseinate in the meal. Study 2 comprised obese subjects with previous RYGB who underwent two 5-hour mixed-meal tests with concomitant exendin-(9−39) or saline infusion. In study 1, the secretion of follistatin as well as the amino acid absorption was accelerated after RYGB compared with SG and controls, but the glucagon-to-C-peptide ratios did not differ between the groups. In study 2, exendin-(9−39) administration increased postprandial glucagon concentrations and lowered insulin secretion, whereas the concentration of follistatin was unchanged. In conclusion, postprandial follistatin secretion is accelerated in patients after RYGB which might be explained by an accelerated protein absorption rate rather than the glucagon-to-insulin ratio.

Conversion of Roux-en-Y gastric bypass to single anastomosis duodenal ileal bypass with sleeve gastrectomy with gastrogastric jejunal bridge

Surgical conversion of Roux-en-Y gastric bypass (RYGB) to one anastomosis duodenal switch with sleeve gastrectomy (SADI-S), can be effective, when there is obesity recidivism, but surgically challenging. This case report video aims to detail the technical modifications that simplifies this conversion, in one stage. This video article demonstrates the conversion of RYGB to SADI-S using a jejunal bridge to facilitating the gastro-gastric reconnection. Surgical conversion was done laparoscopically, firstly removing the fundus, gastric body and the proximal part of the antrum. The gastrojejunal (GJ) anastomosis from the previous RYGB was preserved and the jejunal alimentary limb that follows was transected, 8cm distal to the GJ anastomosis, and anastomosed, at this level, with the antrum. The remaining alimentary limb was removed, until the jejuno-jejuno anastomosis, from the previous RYGB. The interposition of a segment of jejunal alimentary limb between the gastric bypass pouch and the antrum, has shown to be safe and feasible in RYGB conversion to SADI-S, without complications. Not reconnecting the remnant jejunal alimentary limb to the intestinal transit, but removing it, makes the procedure shorter and safer.

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.

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass.

In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass. SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300cm proximal to the ileo-caecal valve and the jejunum 30cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145min. Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA. Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

Pancreaticoduodenectomy after Roux-en-Y Gastric Bypass: a novel reconstruction technique.

The obesity epidemic continues to increase around the world with its attendant complications of metabolic syndrome and increased risk of malignancies, including pancreatic malignancy. The Roux-en-Y gastric bypass (RYGB) is an effective bariatric procedure for obesity and its comorbidities. We describe a report wherein a patient with previous RYGB was treated with a novel reconstruction technique following a pancreaticoduodenectomy (PD). A 59-year-old male patient with previous history of RYGB was admitted with painless progressive jaundice. Imaging revealed a distal common bile duct stricture and he underwent PD. There are multiple options for reconstruction after PD in patients with previous RYGB. The two major decisions for pancreatic surgeon are: (I) resection/preservation of remnant stomach and (II) resection/preservation of original biliopancreatic limb. This has to be tailored to the patient based on the intraoperative findings and anatomical suitability. In our patient, the gastric remnant was preserved, and distal part of original biliopancreatic limb was anastomosed to the stomach as a venting anterior gastrojejunostomy. A distal loop of small bowel was used to reconstruct the pancreaticojejunostomy and hepaticojejunostomy and further distally a new jejunojejunostomy performed. The post-operative course was uneventful, and the patient was discharged on 7th day. With the increase in number of bariatric procedures performed worldwide, pancreatic surgeons should be aware of the varied surgical reconstruction options for PD following RYGB. This should be tailored to the patient and there is no "one-size-fits-all".

SP6.1.7 Meta-analysis of procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography in patients with previous Roux-en-Y gastric bypass surgery

Abstract Aims To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery. Methods We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data. Results A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137 minutes (95% CI 102-172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5-97.5,I2=0%), papillary access success was 95.3% (95% CI 92.5-97.5,I2=0%), cannulation success was 95.3% (95% CI 92.5-97.5,I2=0%), sphincterotomy success was 96.1% (95% CI 93.5-98.1,I2=0%), and stone removal success was 95.9% (95% CI 92.4-98.4, I2=0%). Conversion to open was required in 4.7% (95% CI 2.5-7.6,I2=0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3-8,I2=17%), cholangitis in 1.7% (95% CI 0.5 to 3.6,I2=0%), and perforation in 3.7% (95% CI 1.8- 6.3,I2=0%). The length of hospital stay was 3 days (95% CI 2-4). Conclusions Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.

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.

Procedural Outcomes of Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Roux-en-Y Gastric Bypass Surgery: a Systematic Review and Meta-analysis.

To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery. We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data. A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137min (95% CI 102-172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5-97.5, I2= 0%), papillary access success was 95.3% (95% CI 92.5-97.5, I2= 0%), cannulation success was 95.3% (95% CI 92.5-97.5, I2= 0%), sphincterotomy success was 96.1% (95% CI 93.5-98.1, I2= 0%), and stone removal success was 95.9% (95% CI 92.4-98.4, I2= 0%). Conversion to open was required in 4.7% (95% CI 2.5-7.6, I2= 0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3-8, I2= 17%), cholangitis in 1.7% (95% CI 0.5-3.6, I2= 0%), and perforation in 3.7% (95% CI 1.8-6.3, I2= 0%). The length of hospital stay was 3days (95% CI 2-4). Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.

Sa1970 USE OF THE OVERSTICH DEVICE FOR ENDOSCOPIC REVISION OF ROUX-EN –Y GASTRIC BY-PASS: AN UPDATE FROM THE LARGEST UK SERIES

Patients with Roux-en-Y gastric bypass (RYGB) are able to achieve up to 60% weight loss after surgery. However, 30% of these patients will regain weight within 2 years time following the operation. The options for this group of patients are limited. Changes in life style are not effective in most of the cases and re-do another surgery is associated with high risk of complications and lower weight loss. In some of these patients the main issue is the increase of the stoma diameter with time. The Overstitch device is a minimally invasive endoscopic suturing method that can be employed in this setting to facilitate further weight loss. All patients were discussed in a multidisciplinary bariatric meeting having already undergone a diagnostic gastroscopy to assess suitability for the procedure. The endoscopic inclusion criteria were a stoma of at least 2 cm in diameter and a pouch length greater than 3 cm. Forty patients (38 female) with a previous RYGB and weight regain that met the endoscopic criteria were included with a media stoma size of 4 cm. Initially, the mucosa of the outlet was ablated with APC followed by the use of the overstitch device. The suturing pattern chosen was a mixed one with a media of 2 sutures per patient and final stoma media diameter of 2.9 mm (Fig.1 and Fig.2). All the procedure was performed under general anaesthesia with the patient in supine position. After the procedure, the patients followed a strict diet under supervision and preventive symptomatic treatment was prescribed as well. All patients underwent the procedure safely with no major complications. Only two patients presented abdominal pain and nausea which were easily controlled with antiemetic and pain relief medication. Only one underwent the technique twice because of loose sutures. After 1 year of follow-up an average weight loss of 8.9 kg was observed. Endoscopic revision of the RYGB using the Overstitch device is an effective and safe method of achieving further weight loss in patients who have regained weight post-surgery and have a stoma that meets endoscopic criteria. The weight loss effect was sustained at 1 year post-procedure.The longer term benefots need to be determined but it is possible to repeat the procedure in those patients who regain weight .Fig 2RYGB Outlet After Overstich RevisionView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Combined Laparoscopic Revision of the Gastric Pouch and Distalization of the Roux Limb After Failure of Weight Loss Following Roux-en-Y Gastric Bypass

After failed Roux-en-Y gastric bypass (RYGB), the choice of a secondary procedure falls into many pathways: revision of the gastric pouch, distalization of the bypass (DRYGB), addition of an adjustable gastric band, and conversion to a duodenal switch (BPD/DS). We present the case of a 54-year-old man with initial BMI of 51.5kg/m2, who first underwent laparoscopic sleeve gastrectomy (SG) in 2010. In 2012, he underwent a RYGB procedure, and in 2015, a pouch resizing for weight regain. In 2018, he reached a BMI of 41.2kg/m2. A 3D volumetric CT scan measured a gastric pouch volume of 220cm3 and a gastrojejunal anastomosis diameter of 20mm. As shown in the video, the patient underwent a combined revision of the gastric pouch and the gastrojejunal anastomosis associated to the distalization of the Roux limb. The gastrojejunal anastomosis is identified, and vertical division of the stomach is performed along a 36 French bougie, in order to create a 30cm3 gastric pouch. Then, the jejunojejunal anastomosis is identified, and the Roux limb at the jejunojejunostomy is divided and transposed distally 100cm to create a total alimentary length of 250cm. The postoperative course was uneventful. At 1year, his BMI was 31.2kg/m2. No nutritional deficiencies were noted. Combined laparoscopic pouch resizing and distalization are safe and can lead to adequate weight loss. This technique allows the combination of an added restriction and malabsorption to the previous RYGB and could lead to an improved weight loss.

Pancreatic Head Resection Following Roux-en-Y Gastric Bypass: Operative Considerations and Outcomes

PurposeThis study aimed to identify optimal management decisions for surgeons preforming pancreatic head resection on patients with altered anatomy due to a previous Roux-en-Y gastric bypass (RYGB). MethodsA multi-national (4), multi-center (28) collaborative of 55 pancreatic surgeons who have performed pancreatoduodenectomy or total pancreatectomy following RYGB for obesity (2005–2018) was created. Demographics, operative details, and perioperative outcomes from this cohort were analyzed and compared in a propensity-score matched analysis with a multi-center cohort of 5533 pancreatoduodenectomies without prior RYGB. ResultsNinety-six patients with a previous RYGB undergoing pancreatic head resection were assembled. Pathologic indications between the RYGB and normal anatomy cohorts did not differ. Propensity score matching of RYGB vs. patients with unaltered anatomy demonstrated no differences in major postoperative outcomes. In total 20 distinct reconstructions were employed (of 37 potential options); the three most frequent reconstructions accounted for 52.1%, and none demonstrated superior outcomes. There were no differences in outcomes observed between original biliopancreatic limb use (66.7%) and those where a secondary Roux limb was created for biliopancreatic reconstruction. Remnant stomachs were removed in 54.7% of cases, with no outcome differences between resected and retained stomachs. Venting gastrostomy tubes were used in 36.2% of retained stomachs without obvious outcome benefits. Jejunostomy tubes were used infrequently (11.7%). ConclusionsPancreatic head resection after RYGB is an infrequently encountered, unique and challenging scenario for any given surgeon. These patients do not appear to suffer higher morbidity than those with unaltered anatomy. Various technical reconstructive options do not appear to confer distinct benefits.

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.

Post-thyroidectomy Hypocalcemia in Patients With History of Bariatric Operations: Current Evidence and Management Options.

Both bariatric and thyroid surgeries promote calcium and vitamin D deficiency. The correlation, however, of hypocalcemia after thyroidectomy in patients with previous bariatric surgery has been poorly described. This review aimed to investigate the relationship between history of bariatric operations and post-thyroidectomy hypocalcemia, as well as suggested management options. MEDLINE and Cochrane databases were searched for relevant publications regarding post-thyroidectomy hypocalcemia in patients with previous bariatric surgery. A total of 17 publications reporting on 126 patients met the inclusion criteria. These included 13 publications about Roux-en-Y gastric bypass (RYGB), 2 regarding biliopancreatic diversion (BPD), 1 about sleeve gastrectomy (SG) and 1 compared three bariatric procedures: SG, RYGB, laparoscopic adjustable gastric band (LAGB). Post-thyroidectomy hypocalcemia was found to be more prevalent in patients with previous RYGB and BPD, but not in previous LAGB and SG. Patients with previous bariatric surgery are at high risk of post-thyroidectomy hypocalcemia that sometimes leads to higher length of hospital stay and demands more invasive solutions. There is a need, however, for additional studies and further investigation in order to reach more conclusive results.

Pancreaticoduodenectomy in patients with Roux-en-Y gastric bypass: a matched case-control study

Background: Pancreaticoduodenectomy (PD) is routine for pancreatic head pathology but little is known regarding outcomes of PD in patients with previous Roux-en-Y gastric bypass (RYGB). The aim of this study was to review our experience with PD after RYGB. Methods: A retrospective case-control study of patients undergoing PD after RYGB from 01/2012 to 07/2017 was performed. Patients with RYGB were matched by age, sex, operative approach, pathology, and year of surgery to non-RYGB patients undergoing PD. Demographic and operative outcomes were reviewed and compared. Results: Of 309 patients undergoing PD, 9 (2.9%) had previous RYGB. Mean time between RYGB and PD was 142.8 months. Three patients (33.3%) required percutaneous transhepatic cholangiography (PTC) with subsequent stent placement in two patients (22.2%). Laparoscopic and open approaches were utilized in one and nine patients respectively. The remnant stomach was excised in 5 patients and from remaining four cases; transgastric jejunal feeding tube was placed in two patients. Nine patients with RYGB were matched to 27 non-RYGB (1:3) patients. No differences were found between groups in mean operative time, length of hospital stay or postoperative morbidity (Table 1). More patients with RYGB required PTC and stent placement due to altered anatomy than non-RYGB ones, but this difference did not reach significance. No significant difference was revealed in the time interval between time of diagnosis in asymptomatic patients or date of the first symptoms in symptomatic patients and the date of surgery between comparison groups. No 90-day mortality was noted in the study groups. Conclusion: Past surgical history of RYGB in patients with pancreatic head pathology does not result in delay in PD. PD has comparable outcomes in patients with previous RYGB to those in non-RYGB patients.Tabled 1CharacteristicWith RYGB (n=9)Without RYGB (n=27)P valueAge, y62.1 (7.0)63.8 (7.0)0.53BMI, kg/m229.4 (6.5)27.0 (6.2)0.32Female9(100.0)27 (100.0)>0.99Hypertension9 (100.0)17 (63.0)0.04Cardiac disease4 (44.4)6 (22.2)0.65Diabetes mellitus4 (44.4)5 (18.5)0.18History of pancreatitis2 (22.2)1 (3.7)0.14Previous upper abd. surgeries9 (100.0)3 (11.1)<0.001Asymptomatic1 (11.1)5 (18.5)>0.99Jaundice3 (33.3)8 (29.6)>0.99Time after RYGB, mo142.8 (106.8)……PTC3 (33.3)2 (7.4)0.08PTC with stentplacement2 (22.2)0 (0.0)0.06Diagnosis-Surgery, mo7.3 (5.9)9.3 (18.6)0.75ASA class II0 (0.0)0 (0.0)… III8 (88.9)27 (100.0)0.25 IV1 (11.1)0 (0.0)0.25Resection type Laparoscopic1 (11.1)3 (11.1)>0.99 Open8 (88.9)24 (88.9)>0.99Excision of the RS5 (55.5)……TG jejunal FT2 (22.2)……Operative time, min295.0 (92.6)313.9 (118.6)0.66EBL, ml341.7 (259.8)353.3(454.4)0.94LOS, d6.4 (5.2)6.6 (2.5)0.8790-Day morbidity Minor (CI grade I-II)2 (22.2)8 (29.6)>0.99 Major (CI grade III-V)3 (33.3)9 (24.3)>0.99 CR-DGE0 (0.0)2 (7.4)>0.99 CR-POPF1 (11.1)3 (11.1)>0.99Death0 (0.0)0 (0.0)…Follow-up, mo14.4 (13.2)20.2 (16.1)0.33 Open table in a new tab

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.

A5010 - Reversal of Roux-en-y gastric bypass at a tertiary center with a large experience in laparoscopic gastric bypass revision: indications and outcomes

No large single institution experience in reversal of Roux-en-y gastric bypass (RYGB) to normal anatomy has been previously published. Most published series are small, suggesting that bariatric surgeons may reserve reversal to normal anatomy for rare situations, perhaps due to concern about a high risk for surgical complications. We have been fairly aggressive at recommending reversal to normal anatomy for patients with a variety of chronic serious complications after RYGB. In this report, we describe our large experience with laparoscopic reversal of RYGB over 4 years, our indications for reversal and our post-operative outcomes. The goal of our study is to advance understanding of how reversal to normal anatomy may be applied after previous RYGB, to further define the risks of complications and to identify factors that would prevent the need for reversal.

Mo1635 CT Scan Is Helpful for Internal Hernia Detection Following Weight Loss Surgery

Introduction: Radiographic imagingwith CT scan in patients presentingwith acute abdominal pain following Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS) is becoming commonplace. While surgical exploration remains the gold standard for diagnosing internal hernia, decisions for operative intervention are often based on CT findings. The accuracy of CT scan to reliably identify internal hernia in this subset of patients remains unknown. The purpose of this study is to evaluate the reliability of CT scan as a diagnostic tool to identify internal hernia (IH) in bariatric patients with acute abdominal pain. Methods: Following institutional review board approval, a retrospective chart review of all patients presenting with symptoms concerning for obstruction following Roux-en-Y gastric bypass or BPD/DS switch was performed. Patients without CT scans were excluded. Fifty two patients who underwent an operation for a suspected internal hernia from 2008-2013 were identified from surgeons' records at 2 institutions. CT and intraoperative findings were compared via univariate statistical analysis. Patients with incidental finding of a hernia defect were excluded. Results: Of the 52 patients, 50 had previous RYGB and 2 BPD/DS. There was a higher number of female patients in this population (Table 1). Mean time to presentation was 5 years following initial bariatric procedure (5 months to 14 years). Of the 52 patients, 27 had IH at operation. Thirty one (60%) patients had CT scans read as positive for IH and/or obstruction. Of these 31, 21(68%) were found to have IH at operation and 10 (32%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to identify IH and/or obstruction is 78% with 95% CI [57% to 91%], specificity is 60% with 95% CI [39%-78%], positive predictive value is 68% with 95% CI [49%-83%], and negative predictive value is 71% with 95% CI [48%-88%]. Kappa statistics comparing the agreement between CT findings and operative findings was 0.380 with 95 CI 0.131-0.629, which was consistent with fair agreement. Conclusions: This study examined the utilization of CT scans in detection of internal hernias. Positive CT scan is highly predictive of IH, but not specific. As CT scan will not detect IH in 1:4 patients, despite negative findings surgical exploration should remain the gold standard for patients with acute abdominal pain following RYGB or BPD when IH cannot be ruled out.

Mo1636 Outcomes of Patients With Biopsy-Proven Sclerosing Mesenteritis

Introduction: Radiographic imagingwith CT scan in patients presentingwith acute abdominal pain following Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS) is becoming commonplace. While surgical exploration remains the gold standard for diagnosing internal hernia, decisions for operative intervention are often based on CT findings. The accuracy of CT scan to reliably identify internal hernia in this subset of patients remains unknown. The purpose of this study is to evaluate the reliability of CT scan as a diagnostic tool to identify internal hernia (IH) in bariatric patients with acute abdominal pain. Methods: Following institutional review board approval, a retrospective chart review of all patients presenting with symptoms concerning for obstruction following Roux-en-Y gastric bypass or BPD/DS switch was performed. Patients without CT scans were excluded. Fifty two patients who underwent an operation for a suspected internal hernia from 2008-2013 were identified from surgeons' records at 2 institutions. CT and intraoperative findings were compared via univariate statistical analysis. Patients with incidental finding of a hernia defect were excluded. Results: Of the 52 patients, 50 had previous RYGB and 2 BPD/DS. There was a higher number of female patients in this population (Table 1). Mean time to presentation was 5 years following initial bariatric procedure (5 months to 14 years). Of the 52 patients, 27 had IH at operation. Thirty one (60%) patients had CT scans read as positive for IH and/or obstruction. Of these 31, 21(68%) were found to have IH at operation and 10 (32%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to identify IH and/or obstruction is 78% with 95% CI [57% to 91%], specificity is 60% with 95% CI [39%-78%], positive predictive value is 68% with 95% CI [49%-83%], and negative predictive value is 71% with 95% CI [48%-88%]. Kappa statistics comparing the agreement between CT findings and operative findings was 0.380 with 95 CI 0.131-0.629, which was consistent with fair agreement. Conclusions: This study examined the utilization of CT scans in detection of internal hernias. Positive CT scan is highly predictive of IH, but not specific. As CT scan will not detect IH in 1:4 patients, despite negative findings surgical exploration should remain the gold standard for patients with acute abdominal pain following RYGB or BPD when IH cannot be ruled out.