Prior Roux-en-Y Gastric Bypass Research Articles

8396 Growth Hormone Secretion after Glucagon Stimulation is Increased in Individuals with History of Bariatric Surgery

Abstract Disclosure: L. Pei: None. C. Cummings: None. H. Saeed: None. M. Farahmandsadr: None. A. Amore: None. A. Sheehan: None. R. Ferraz-Bannitz: None. D.C. Simonson: Stock Owner; Self; GI Windows. Other; Self; wife owns Phase V Technologies. M. Patti: Advisory Board Member; Self; data and safety monitoring board on Fractyl Health. Consulting Fee; Self; AstraZeneca, Hamni, MBX Biosciences. Grant Recipient; Self; Receive investigator-initiated research funding from Dexcom. Background: Growth hormone (GH) is an important counterregulatory hormone and regulator of hepatic glucose metabolism. Previous studies demonstrated increased plasma GH and reduced plasma growth hormone receptor (GHR) after bariatric surgery in both rodents and humans. Moreover, plasma GHR was identified as mediator of improved glycemic control after Roux-en-Y gastric bypass (RYGB). We now test the hypothesis that altered GH and/or GHR levels contribute to post-bariatric hypoglycemia (PBH). Methods: Cross-sectional studies were performed at a single academic institution. GH secretion was assessed after 1mg IV glucagon (GCG) and during hyperinsulinemic-hypoglycemic clamp in 3 groups: 1) post-RYGB without hypoglycemia symptoms (RnonH) (20F, age 51±11 (mean±SD) y, BMI 35±8 kg/m2, HbA1c 5.2±0.3%, 10.6±5.3 years post-surgery), 2) PBH (18F/2M, age 54±12y, BMI 30.5±4.6 kg/m2, HbA1c 5.2±0.3%, 9.4±6.0 years post-surgery), 3) weight-similar controls without upper GI surgery (CON) (6F/4M, age 47.1±13.1y, BMI 31.9±5.7 kg/m2, HbA1c 5.4±0.3%). Plasma GHR and GH were measured via ELISA. Results: Fasting GH did not differ between groups (mean±SE, CON: 285±78, RnonH: 860±179, PBH: 980±284 pg/mL, P=0.16). Peak incremental glucose response to GCG, ranging from 46-59 mg/dL, did not differ between groups. At 120 min after GCG, GH was significantly higher in both PBH and RnonH vs. CON (PBH: 3018±678, RnonH: 2521±656, CON: 481±137 pg/mL, ANOVA P= 0.012, PBH vs. CON P=0.003, RnonH vs. CON P=0.02). Peak GH in PBH was significantly higher vs. CON (3431± 655 vs. 547±153 pg/mL, P=0.03), but did not differ in RnonH vs. PBH. Peak GH was inversely correlated with postoperative duration in PBH only (r=-0.49, P=0.03), with BMI in both surgical groups (PBH: r=-0.49, P=0.03, RnonH: r=-0.57, P=0.009) and with percent body fat (impedance plethysmography) in the combined surgical group (r=-0.51, P=0.0007). In contrast, GH during hyperinsulinemic hypoglycemia did not differ between groups (CON: 9660 ±2588, RnonH: 7759±1751, PBH: 7309±1549 pg/mL, P=0.3) at similar degrees of hypoglycemia (CON: 54.8±1.5, RnonH: 50.7±1.0, PBH: 50.9±1.4 mg/dL). Fasting plasma GHR did not differ (CON: 23.3±3.8, RnonH: 19.4±2.8, PBH: 13.8±2.1 ng/mL, P=0.10). GHR was correlated with percent fat mass in the combined surgical group (r=0.56, P=0.0003) but not in CON. Conclusion: Plasma GH did not differ as a function of prior RYGB, with or without hypoglycemia, in the fasting state or in response to insulin-induced hypoglycemia. However, GCG-stimulated GH levels were 5-6-fold higher in individuals with history of RYGB, numerically higher in PBH, and inversely related to body fat and postop duration. Together these results suggest that reduced GH is not likely driving hypoglycemia in PBH, but that alterations in glucagon-mediated GH secretion and/or action may contribute to observed metabolic effects of RYGB. Presentation: 6/1/2024

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.

Is open-capsule proton pump inhibitor associated with faster healing time for marginal ulceration after Roux-en-Y gastric bypass?

BackgroundMarginal ulceration (MU) is a significant cause of morbidity after Roux-en-Y gastric bypass (RYGB). Proton pump inhibitors (PPIs) are the primary treatment. Prior limited data suggest that open-capsule PPIs (OC-PPIs) improve MU healing compared with intact-capsule PPIs (IC-PPIs), necessitating further validation. ObjectivesWe aimed to compare healing times of MU after RYGB when treated with OC-PPIs versus IC-PPIs. SettingTertiary academic center, United States. MethodsWe retrospectively analyzed patients with prior RYGB diagnosed with MU from 2012 to 2022. Patients requiring mechanical closure without documented healing and without clear PPI prescriptions were excluded. The primary outcome was time to ulcer healing. Log-rank testing and Kaplan–Meier survival curve analyses were performed to compare MU healing times when treated with OC-PPIs versus IC-PPIs. Subgroup analyses further characterized ulcer healing times based on type and dosage of PPI used. ResultsA total of 108 patients were included for final analysis (38 received OC-PPIs and 70 received IC-PPIs). Treatment with OC-PPIs significantly decreased MU healing time compared with IC-PPIs (146.18 versus 226.14 d; p = .018). However, when stratified by PPI potency, the positive effect of opening the capsule lost significance. ConclusionIn this study, OC-PPIs significantly improved MU healing times compared with IC-PPIs in RYGB patients, consistent with prior data. However, on subgroup analysis comparing therapy with similar PPI potency, the MU healing time did not differ with respect to administration method. These results highlight the need for a prospective randomized trial to compare the true effect of administration method.

SAT143 Domains Of Cognitive Dysfunction In Patients With Post-Bariatric Hypoglycemia

Abstract Disclosure: A.M. Puleio: None. A.L. Sheehan: None. G.J. Musen: None. M. Patti: Consulting Fee; Self; AstraZeneca, Fractyl Laboratories. Other; Self; Eiger Pharmaceuticals - Consulting, MBX Biosceinces - Consulting, Hanmi Pharmaceutical - Consulting, Recordati - Consulting. Objective: Bariatric surgery is a highly effective treatment for obesity and associated comorbidities. Studies suggest bariatric surgery may result in improved cognitive function and brain volume in parallel with improved cardiometabolic function. However, some post-bariatric individuals develop post-bariatric hypoglycemia (PBH), which can be frequent and severe. Whether repeated episodes of hypoglycemia can impact cognitive function in PBH is unknown. The objective of this pilot study was to determine whether individuals with PBH display reduced cognitive function compared to surgical non-hypoglycemic counterparts. Inclusion/Exclusion Criteria: Adults aged 18-70 years, with a history of Roux-en-Y gastric bypass (RYGB), without a current diagnosis of diabetes, were recruited and enrolled into two groups: individuals with PBH (PBH+), and asymptomatic individuals with history of prior RYGB without hypoglycemia (RYGB non-hypo). Individuals with a history of traumatic brain injury or cerebrovascular accident, active treatment with any medications for diabetes (other than acarbose), active alcohol/substance abuse, known neuroendocrine tumor, or active depression (score >4 for Patient Health Questionnaire-2 (PHQ-2)) were excluded. Methods: Fourteen adults (PBH+, n=7; RYGB non-hypo, n=7) completed assessments of executive function (Delis Kaplan Executive Function System), working memory and attention (Wechsler Memory Scale Third Edition), as well as psychomotor speed (grooved pegboard). Premorbid intelligence was estimated using the National Adult Reading Test. Results: Individuals with PBH+ displayed significantly decreased performance on tests of category fluency (p <0.01), category switching (p <0.01), and category switching accuracy (p <0.01), compared to those in the RYGB non-hypo group. Performance in other verbal fluency measures, including the first (p =0.03) and third interval (p = 0.045), were significantly lower in PBH+ vs. RYGB non-hypo. All other assessments did not differ, including the estimation of premorbid intelligence (p=0.14). Conclusion: PBH+ individuals may be at greater risk for cognitive impairment compared to RYGB non-hypo individuals, as suggested by the impaired semantic processing and cognitive flexibility, as well as greater difficulty initiating and sustaining word retrieval in PBH+. Groups did not differ in cognitive assessments of psychomotor speed, memory, attention, and executive function. Clinicians should be alert for symptoms of cognitive dysfunction in PBH+ patients and consider neurocognitive testing in parallel with assessment of glycemic control, as well as other potential cognitive risk factors. Larger, longitudinal trials are necessary to further elucidate the impact of hypoglycemia on cognition and risk of dementia in patients with PBH. Presentation: Saturday, June 17, 2023

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass.

Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia. This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change. A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms. TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

Hypocalcemia After Thyroidectomy in Patients with Prior Bariatric Surgery: A Propensity Score Matched Analysis from a National Administrative Database.

Background: Studies have suggested that patients with prior gastric bypass may be at increased risk for hypocalcemia following thyroidectomy. Unfortunately, most of these studies are limited to case reports and small series. This study represents the largest sample size to date to assess the incidence of post-thyroidectomy hypocalcemia in patients with a history of bariatric surgery. Methods: The TriNetX Research Network was queried to retrospectively identify patients with prior bariatric surgery who underwent total thyroidectomy between 2011 and 2021. The incidence of hypocalcemia following surgery was compared with patients who underwent total thyroidectomy, and hemithyroidectomy with no history of bariatric surgery. Results: We identified 446 patients with a history of bariatric surgery and subsequent thyroidectomy, 29,346 patients with total thyroidectomy, and 19,603 patients with hemithyroidectomy alone. The one-month incidence of hypocalcemia was 54.7% in those with a history of bariatric surgery who underwent thyroidectomy, 43.9% in those with thyroidectomy alone (relative risk, RR = 1.2 [confidence interval, CI 1.1-1.4], p < 0.001), and 8.1% in those with hemithyroidectomy only (RR = 6.8 [CI 6.1-7.4], p < 0.001). Permanent hypocalcemia was documented in 11.4% of patients with prior bariatric surgery who underwent thyroidectomy, 7.7% of those with thyroidectomy only (RR = 1.5 [CI 1.1-1.9], p = 0.003), and 2.9% of patients with hemithyroidectomy alone (RR = 3.9 [CI 3.0-5.2], p < 0.001). Significant differences persisted after matching demographics, prior need for supplementation, and risk factors for hypocalcemia after thyroidectomy. When stratified by bariatric procedure, patients with a history of Roux-en-Y gastric bypass (RYGB) (n = 35) had a greater, although not statistically significant, risk of short-term hypocalcemia (51.4%; RR = 1.2 [CI 0.8-1.6], p = 0.37), and a significantly increased risk of permanent hypocalcemia (20.0%; RR = 2.6 [CI 1.3-5.1], p = 0.005) compared with thyroidectomy alone. Sleeve gastrectomy (SG) (n = 40) was not associated with an increased risk of short-term (40.0%; RR = 0.9 [CI 0.6-1.3], p = 0.62) or permanent (7.5%; RR = 1.0 [CI 0.3-2.9], p = 0.96) hypocalcemia. Conclusions: Prior RYGB, but not SG, may increase the risk of permanent hypocalcemia after thyroidectomy. Additional research is necessary to determine optimal prevention and treatment strategies to reduce morbidity in this population.

S2871 Successful Treatment of “Candy Cane” Syndrome Through Endoscopic Gastrojejunal Anastomosis Revision

Introduction: “Candy cane” syndrome is a post-surgical Roux-en-Y gastric bypass (RYGB) complication associated with a markedly long, surgically-created blind end of the afferent Roux limb distal to the gastrojejunostomy. Gradual filling of this long blind limb with food can result in symptoms, including postprandial epigastric pain, nausea, vomiting, or regurgitation. Treatment of candy cane syndrome traditionally consists of laparoscopic resection of the redundant blind afferent limb. We present the first case of successful treatment of candy cane syndrome through endoscopic revision of the gastrojejunal (GJ) anastomosis. Case Description/Methods: A 40-year-old female presented for evaluation of intractable acid reflux, nausea, and weight recidivism eight years post RYGB. Esophagogastroduodenoscopy revealed evidence of prior RYGB, a healthy-appearing GJ anastomosis, a direct path across the GJ anastomosis into the blind afferent limb, and the enteral efferent limb located at a more angulated orientation toward the 4:00 position. An upper gastrointestinal series revealed an exaggerated blind afferent limb with pooling of contrast in the afferent blind limb before spilling to progress down the Roux limb. This finding suggested the reflux likely stemmed from the excessively long blind afferent limb. The patient wished to avoid surgery and a novel endoscopic suturing technique was performed that narrowed the GJ anastomosis and oriented flow towards the enteral efferent limb. This resulted in 1) limiting acid reflux 2) assisting with weight loss and 3) redirecting flow of contents more toward the enteral efferent limb. Post-procedure our patient had no additional weight gain and her acid reflux and nausea resolved. (Figure) Discussion: Candy cane syndrome is an underappreciated complication reported following RYGB. It results from an excessively long blind afferent Roux limb at the gastrojejunostomy that can lead to food accumulation. Patients often present with nausea, vomiting, food intolerance, acid reflux, and abdominal pain. Many patients remain undiagnosed due to vague gastrointestinal symptoms, delayed presentation, and physician unawareness. Historically, treatment has required surgical revision. Endoscopic suturing revision of the GJ anastomosis can provide an alternative less invasive and possibly safer treatment option that address the reflux symptoms, weight regain, and aberrant flow of contents into the blind limb.Figure 1.: Figure: Endoscopic view of direct access into the blind afferent limb A, the acute angle of the enteral efferent limb B, and dilated gastrojejunal anastomosis C.

Ampullary stenosis and choledocholithiasis post Roux-En-Y gastric bypass: challenges of biliary access and intervention

BackgroundAmpullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and choledocholithiasis to illustrate the associated diagnostic and interventional challenges with this condition. MethodsWe reviewed medical records of patients with prior RYGB who underwent a biliary access procedure or surgery for non-malignant disease from January 2012–December 2018. ResultsWe identified 15 patients (4 male, 11 female; mean age 53.7 years) who had RYGB on average 11.7 years (range 1–32) years before diagnosis of biliary obstruction. Fourteen patients reported abdominal pain, 5 had nausea/emesis, 12 had elevated liver function tests, and 6 had ascending cholangitis. Mean common bile duct (CBD) diameter at presentation was 16.9 mm (range 4.0–25.0 mm). Operations included 3 transduodenal ampullectomies (2 with biliary bypass), 2 CBD explorations with stone extraction, 1 laparoscopic cholecystectomy alone, 1 Whipple procedure, 1 balloon enteroscopy with sphincterotomy, and 7 transgastric endoscopic retrograde cholangiopancreatography. All ampulla pathology was benign in patients who underwent resection. At follow-up (mean 15.4 months; range 0.23–44.5 months), 12/15 (80%) reported symptom resolution or improvement. DiscussionAmpullary stenosis after RYGB presents challenges for diagnostic evaluation and intervention, often requiring multi-disciplinary expertise. The underlying pathology remains to be elucidated.

2777 Nutritional Deficiencies in a Patient With Roux-en-Y Gastric Bypass Surgery

INTRODUCTION: Bariatric surgery is one of the most commonly performed surgeries in the US. Several types exist including vertical sleeve gastrectomy (VSG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB). VSG and RYGB work through caloric restriction and neurohormonal changes. While there are many benefits of bariatric surgeries, there are also many complications including malabsorption of nutrients. CASE DESCRIPTION/METHODS: A 41-year-old African-American female with prior RYGB in 2014 presented to the hospital with general malaise, crampy abdominal pain, back and joint pain, nausea, dyspnea, and intermittent headaches with photophobia and phonophobia for the past 1 month. Labs revealed moderate microcytic anemia with hemoglobin of 9. Reticulocytes were depressed at 13.8. Metabolic panel was within normal limits. Rheumatologic panel including ANA, C3/C4 was negative. On exam, pertinent findings included tachycardia and epigastric tenderness with deep palpation. She had multiple 1 cm hyperpigmented circular lesions on the forehead, upper back, and bilateral upper arms. This prompted testing for copper and zinc, which were decreased at 26 and 54, respectively. CT abdomen/pelvis with contrast showed a small pericardial effusion but was otherwise normal. MRI brain showed no changes to prior images. The patient was discharged on a multivitamin with zinc and copper to follow up with her PCP. DISCUSSION: Copper and zinc are essential nutrients for humans and act as cofactors for a variety of metalloenzymes that participate in critical body functions. Deficiency in these nutrients is rare in the US as it’s found in commonly consumed foods. Copper deficiency results in brittle hair, skin depigmentation, neurologic dysfunction, and osteoporosis. Zinc deficiency can result in pustular skin rash, impaired taste, and immune dysfunction 4Zinc and copper are usually not added to multivitamins and not routinely measured by physicians, however patients with modified GI physiology due to bariatric surgery can be at risk. RYGB reduces the stomach’s capacity and re-routes ingested food to bypass the duodenum, where copper and zinc are absorbed. Patients with a history of gastric bypass surgery and ill-defined symptoms should be tested for trace mineral deficiencies. Patients who recently underwent a gastric bypass, particularly a RYGB, should be placed on a multivitamin that includes zinc and copper.

A283 Endoscopic Gastric and Gastrojejunostomy Plication for Revision of Gastric Bypass

Nearly 20% of patients either fail to achieve goal body weight or experience weight regain following Roux-en-Y gastric bypass (RYGB). Endoscopic reduction of gastric pouch volume and gastrojejunostomy diameter carries reduced risk relative to operative revision, but long-term results have not been demonstrated. We hypothesized that endoscopic revision of prior RYGB may be an effective weight loss technique.

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.

Large series examining laparoscopic adjustable gastric banding as a salvage solution for failed gastric bypass

BackgroundThe Roux-en-Y gastric bypass (RYGB) has long been considered the gold standard of weight loss procedures. However, there is limited evidence on revisional options with both minimal risk and long-term weight loss results. ObjectiveTo examine percent excess weight loss, change in body mass index (BMI), and complications in patients who underwent laparoscopic adjustable gastric banding (LAGB) over prior RYGB. SettingAcademic hospital. MethodsRetrospective analysis of a single-center prospectively maintained database. Three thousand ninety-four LAGB placements were reviewed; 139 were placed in patients with prior RYGB. ResultsAt the time of LAGB, the median BMI was 41.3. After LAGB, we observed weight loss or stabilization in 135 patients (97%). The median maximal weight loss after LAGB was 37.7% excess weight loss and −7.1 change in BMI (P < .0001). At last follow-up visit, the median weight loss was 27.5% excess weight loss and −5.3 change in BMI (P < .0001). Median follow-up was 2.48 years (.01–11.48): 68 of 132 eligible (52%) with 3-year follow-up, 12 of 26 eligible (44%) with 6-year eligible follow-up, and 3 of 3 eligible (100%) with >10-year follow-up. Eleven bands required removal, 4 for erosion, 4 for dysphagia, and 3 for nonband-related issues. ConclusionsLAGB over prior RYGB is a safe operation, which reduces the surgical risks and nutritional deficiencies often seen in other accepted revisional operations. Complication rates were consistent with primary LAGB. Weight loss is both reliable and lasting, and it can be considered as the initial salvage procedure in patients with failed gastric bypass surgery.

Peroral endoscopic myotomy for the treatment of achalasia patients with Roux-en-Y gastric bypass anatomy.

The outcome of peroral endoscopic myotomy (POEM) in patients with prior Roux-en-Y gastric bypass (RYGB) is not known and some experts have recommended against its performance in this patient population because of the risk of postoperative regurgitation. The aim of this study was to report on the outcomes of POEM in patients with RYGB anatomy. Patients with RYGB anatomy who underwent POEM for the treatment of achalasia at three tertiary centers were included. POEM was performed in standard fashion using the anterior or posterior approach. Clinical response was defined by a decrease in Eckardt score to ≤ 3. Results of esophageal acid exposure testing/pH-impedance and manometric testing after POEM were reported when available. A total of 10 achalasia patients with prior RYGB surgery underwent POEM. All procedures were technically successful with anterior myotomy performed in seven patients. The mean submucosal tunnel length and myotomy length were 12.9 cm and 11.1 cm, respectively. The mean procedure time was 72 minutes and mean length of hospital stay was 1.5 days. Clinical success was achieved in all 10 patients with a significant decrease in Eckardt score from 6.5 to 1 (P < 0.001). None of the patients experienced post-procedural regurgitation. Post-procedural pH testing was obtained in six patients and was normal in all of them. This study suggests the feasibility, safety, and efficacy of POEM in patients with prior RYGB surgery. The risk of gastroesophageal reflux disease in these patients seems to be minimal after POEM.

Association of Maternal Roux-en-Y Gastric Bypass with Obstetric Outcomes and Fluid Intelligence in Offspring.

The purpose of the study is to assess whether Roux-en-Y gastric bypass (RYGB) prior to pregnancy is associated with fluid intelligence in offspring. Additionally, perinatal and obstetric outcomes, and children nutritional status were evaluated. Singleton births of women who underwent RYGB between 2000 and 2010 (BS) were matched to two control births by maternal age, delivery year, and gender. Control group 1 (CG1) and control group 2 (CG2) included women with a pre-pregnancy body mass index (BMI) < 35kg/m2 and ≥ 35kg/m2, respectively, who had never undergone bariatric surgery. Thirty-two children from each group (n = 96) were analyzed, mostly female (59%) and Caucasian (82%), with a mean age of 7 ± 2years. Their general intelligence scores were similar after adjusting for sociodemographic confounders; family economic class was the strongest predictor (low: β = - 20.57; p < 0.001; middle: β = - 9.34; p = 0.019). Gestational diabetes mellitus (OR 0.06; 95% CI 0.03; 0.35) and hypertensive disorders (OR 0.09; 95% CI 0.01; 0.40) were less frequent in BS than CG2. Post-RYGB pregnancies were associated with lower birth weight (P = 0.021) than controls. Child overweight and obesity was higher (OR 4.59; 95% CI 1.55; 13.61; p = 0.006) in CG2 (78%) than CG1 (44%) and similar to BS (65%). RYGB prior to pregnancy was not associated with fluid intelligence in offspring. Prior RYGB was associated with a lower frequency of gestational diabetes mellitus and hypertensive disorders than in women with a pre-pregnancy BMI ≥ 35kg/m2, as well as with lower birth weight than both control groups.

Exploring the Excluded Territory: A Case of Signet Cell Cancer of the Excluded Stomach

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed weight reduction surgeries. Evaluation of diseases of the excluded stomach such as ulcers or malignancy pose a significant challenge due to difficulty in accessing the excluded portion of stomach. We report a case of gastric cancer of the excluded stomach diagnosed using advanced endoscopy techniques. A 40-year-old female with Roux-en-Y gastric bypass surgery performed 13 years ago for morbid obesity presented with epigastric pain and weight loss. She was recently diagnosed with bilateral metastatic signet cell carcinoma of the ovaries for which she was on chemotherapy. Her family history was significant for gastric cancer in maternal aunt. Abdominal computerized tomography (CT) was unremarkable. Esophagoduodenoscopy failed to examine the excluded stomach due to limited length of scope and was otherwise normal. Colonoscopy was unremarkable. The excluded stomach was subsequently approached using antegrade double balloon enteroscopy (ADBE) via afferent limb of Roux-en-Y bypass. A large infiltrative ulcerated circumferential mass was found in the prepyloric region and antrum of the stomach. Biopsies were negative for H. pylori infection and revealed invasive signet cell gastric adenocarcinoma that likely had metastasized to the ovaries. Gastric cancer is the fifth most common malignancy worldwide and the fourth leading cause of cancer-related deaths. RYGB is associated with a 4-fold reduction in incidence of gastric cancer in animal models. Tinoco et al reported the incidence of gastric cancer in the excluded stomach to be 0.03% among 3047 patients who underwent bariatric surgery. However, larger prospective studies are lacking regarding incidence of cancer in this population. Risk factors for gastric cancer include H. pylori infection, smoking, high-salt intake, family history of stomach cancer, obesity and a diet low in fruits and vegetables. Symptoms are non-specific like anorexia, epigastric pain, anemia and weight loss following a period of stability or weight gain. Minimal invasive techniques which can be used to evaluate the excluded stomach are ADBE, percutaneous endoscopy, virtual gastroduodenoscopy, laparoscopic transgastric endoscopy and endoscopic ultrasound (EUS). Patients with prior RYGB presenting with alarming, new onset, unexplained symptoms should prompt evaluation including adequate visualization of the excluded stomach with imaging and advanced endoscopic techniques.Figure: showing postoperative anatomy of modern RYGB.Figure: showing endoscopic view of Infiltrative ulcerated mass in prepyloric region and antrum of stomach (black arrow).Figure: Histopathology slide showing signet cell gastric adenocarcinoma (black arrow).

A Novel Endoscopic Technique to Diagnose Gastric Cancer in the Excluded Stomach After Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed weight reduction surgeries. Evaluation of diseases of the excluded stomach (Figure 1) such as ulcers or malignancy pose a significant challenge due to difficulty in accessing the excluded portion of the stomach. We report the first case of the gastric cancer of the excluded stomach diagnosed with endoscopic ultrasound (EUS). A 50-year-old female with Roux-en-Y gastric bypass surgery performed six years ago presented with epigastric pain, nausea and recurrent gastrointestinal bleeding for nine months. Multiple upper and lower gastrointestinal (GI) endoscopies, as well as a video capsule endoscopy failed to identify the source of her recurrent bleeding. Abdominal computed tomography (CT) scan showed a mass in the excluded stomach with enlarged lymph nodes in the perigastric region and gastrohepatic ligament. An EUS via gastric pouch showed diffuse wall thickening of the excluded stomach at the antrum (Figure 2) and two enlarged lymph nodes in the gastrohepatic ligament. Fine needle aspiration (FNA) of the lymph nodes and the gastric wall of the excluded stomach revealed poorly differentiated gastric adenocarcinoma (Figure 3). The biopsy was negative for H. pylori infection. Staging laparoscopy confirmed peritoneal implants. Gastric cancer is the fifth most common malignancy worldwide and fourth leading cause of cancer-related deaths. RYGB is associated with a 4-fold reduction in the incidence of gastric cancer in animal models. Tinoco et al reported the incidence of gastric cancer in the excluded stomach to be 0.03% among 3047 patients who underwent bariatric surgery. However, larger prospective studies are lacking regarding the incidence of cancer in this population. Risk factors for gastric cancer include H. pylori infection, smoking, high-salt intake, family history of stomach cancer, obesity and a diet low in fruits and vegetables. Symptoms are non-specific and include anorexia, epigastric pain, anemia and weight loss following a period of stability or weight gain. Minimal invasive techniques which can be used to evaluate the excluded stomach are double balloon enteroscopy (DBE), percutaneous endoscopy, virtual gastroduodenoscopy, laparoscopic transgastric endoscopy and EUS. Patients with prior RYGB presenting with alarming, new onset, unexplained symptoms should prompt evaluation including adequate visualization of the excluded stomach with imaging and advanced endoscopic techniques.Figure: showing postoperative anatomy of modern RYGB.Figure: EUS showing antral wall thickening in the excluded stomach (arrow).Figure: Histology slide showing poorly differentiated adenocarcinoma.

Su1368 Single-Session ERCP Utilizing PATENT Technique: a Case Series in Patients With Previous Roux-en-Y Gastric Bypass

ERCP remains technically challenging following Roux-en-Y gastric bypass (RYGB). Retrograde ERCP using balloon enteroscopes (BE) as well as surgical, percutaneous, and EUS-guided access to the excluded stomach for antegrade ERCP have all been described. Percutaneous-assisted transprosthetic endoscopic therapy (PATENT) is a novel technique which has recently been described (GIE 2012;76(3):641-4). We previously reported a case of single session antegrade ERCP via transgastric access utilizing PATENT technique in a patient with prior RYGB (GIE 2012;75:1258-63). Here we present a case series of this technique.

Percutaneous Gastrostomy Tube Placement to Perform Transgastrostomy Endoscopic Retrograde Cholangiopancreaticography in Patients with Roux-en-Y Anatomy

Roux-en-Y gastric bypass (RYGB) surgery is one of the most commonly performed bariatric surgeries in the United States. Patients with prior RYGB are not amenable to conventional endoscopic retrograde cholangiopancreaticography (ERCP). Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP). Eleven patients with RYGB anatomy received open Stamm gastrostomy after which the tract was then allowed to mature for an average of 45days before therapeutic TG-ERCP. The success rate and procedure-related complications of both gastrostomy and ERCP were assessed. TG-ERCP was performed on eleven patients (median age 52years, range 37-61years) with prior RYGB and pancreatobiliary diseases. Indications for ERCP in these patients included suspected gallstone pancreatitis (n=4), ampullary/biliary strictures (n=5), pancreas divisum (n=1), and common bile duct clipping as a result of RYGB surgery (n=1). Two individuals developed post surgical complications with stomal-related infections. TG-ERCP with therapeutic intervention was successfully performed in all patients. Intervention included stone extractions (n=11), biliary stricture dilation (n=11), biliary sphincterotomy (n=11), biliary (n=3) and pancreatic (n=1) stent placement, ampullary biopsies (n=3), choledochoscopy (n=1), and pseudocyst drainage (n=1). Complications included post-ERCP pancreatitis (n=2), post-sphincterotomy bleeding (n=1), gastrostomy site bleed (n=1), and gastric perforation (n=1). The total number of ERCP sessions for the eleven patients was 15 (1 or 2 per patient). Median follow-up was 42days (range 7-123days). Surgical open gastrostomy followed by TG-ERCP enables therapeutic intervention but is associated with significant complications.