Proximal Gastric Bypass Research Articles

Long-term weight loss of distal gastric bypass is moderately superior compared to proximal gastric bypass in patients with a BMI of 37-44 Kg/m2.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the standard procedures in metabolic surgery. Different limb lengths have been proposed in the past to maximize weight loss (WL) and reduce metabolic complications. Distal gastric bypass surgery with a very short common channel (CC) (up to 100cm) has been often criticized due to frequent side effects such as malnutrition, bone weakening and short-bowel syndrome. We introduced a modified version of a distal LRYGB with a 50-70cm long biliopancreatic limb (BPL) and an intermediate short CC (120-150cm). Our primary goal was to compare the long-term WL between distal and proximal LRYGB in two cohorts of patients. Secondary outcomes were weight regain (WR), insufficient weight loss (IWL), postoperative complications and metabolic changes 5 years after surgery. In this retrospective study we collected data from 160 patients operated between 2014 and 2015, with a BMI of 37-44 Kg/m2. 101 patients underwent a distal and 59 patients a proximal LRYGB in two bariatric centers. WL was calculated as percent of excess of BMI loss (%EBMIL), loss of body mass index (Delta-BMI), percent of excess weight loss (%EWL) and percent of total weight loss (%TWL). Data were collected 3, 6, 9, 12, 24, 48 and 60 months after surgery. The distal LRYGB resulted in significantly better 5-year-WL compared to the proximal bypass in terms of %EBMIL (median at 5 years: 83% vs. 65%, p = 0.001), %TWL (median at 5 years: 32% vs. 26%, p = 0.017) and %EWL (median at 5 years: 65% vs. 51%, p = 0.029), with equal major complications and metabolic alterations. In addition, WR was significantly lower in patients with distal bypass (18% vs. 35%, p = 0.032). Distal LYRGB with a 120-150 long CC results in better WL and WL-maintenance compared to proximal LRYGB without major side effects after five years.

Does the change from conventional circular to linear stapling in proximal gastric bypass surgery affect long-term quality of life?

Abstract Objective The continuous desire to improve bariatric surgery outcomes, and therefore patient satisfaction, leads to a constant search for new surgical approaches. Every change in a well-established protocol needs to undergo evaluation and its benefit for patients must be demonstrated. With respect to technical changes in bariatric surgery, long-term effects on quality of life have not yet been studied. We analyzed quality of life scores and clinical outcomes at a single bariatric center transitioning from circular to a linear bypass protocol. Methods Between June 2012 and March 2016, 235 patients were included in this retrospective study from a prospectively collected database. Two groups were compared. Group CBP included those patients treated with a circular stapling bypass protocol (n=117). This protocol was primarily used in 2012. Between 2013 and 2015 a transition period occurred. Thereafter, the linear stapling bypass protocol (Group LBP, n=118) was primarily utilized. Quality of life (QoL) was assessed with the Moorehead-Ardelt QoL score, which was gathered preoperatively, and at 1, 2, and 5 years after surgery. Results Quality of life scores improved significantly after intervention in both study groups. The most prominent improvement was seen within the first year after surgery. There were no statistically significant differences between the groups. During the first two years, quality of life score improvement occurred independently of achieved weight loss, whereas a correlation between QoL-improvement and reported weight loss was identified between 24 and 60 months postoperatively (r2 0.112, p<0.001). Further, complications had no impact on change in QoL scores. Conclusion Quality of life scores assessed by the Moorehead-Ardelt QoL questionnaire were, independent of operative technique and postoperative weight loss, significantly improved in the first two years after gastric bypass surgery. Thereafter, QoL scores showed lasting improvement in correlation with further weight loss.

Improved outcomes in proximal gastric bypass surgery following the transition from a conventional circular stapling to an augmented linear stapling protocol

Abstract Objective Bariatric techniques for bypass surgery evolve constantly. Switching from one well-established protocol to another in a running surgical teaching program is challenging. We analyzed clinical outcomes, safety and costs at a single bariatric center transitioning from circular to an augmented linear bypass protocol. Methods Between 2011 and 2018, 454 patients were included in this retrospective study. The circular bypass protocol (CIRC; n=177) was primarily used between 2011–2012. Between 2013–2015 the transition occurred. Thereafter, the augmented linear protocol (aLIN; n=277) was primarily utilized. Results Overall, mean preoperative BMI dropped from 42.2 kg/m2 to 29.6 kg/m2 after 5 years with no difference between groups. Operation times were significantly shorter in the aLIN-group, compared with CIRC-patients at 108 (±32) vs. 120 (±34) minutes (P<0.001), respectively. The reoperation rate was significantly higher in the CIRC vs. aLIN group at n=65 (36%) vs. n=35 (13%; P<0.001), respectively. Specifically, revision due to internal hernia occurred much more frequently in the CIRC-group, n=36 (20%) vs. n=12 (4%; P<0.001). Moreover, reoperation due to gastrojejunostomy-leakage and endoscopic dilatation for anastomotic stenosis was more common in the CIRC vs. aLIN group (P<0.001). Adjusted overall cost per case was lower in aLIN-patients at 15,403 (±7,848) vs. CIRC-patients at 18,525 (±7,850) Swiss Francs (P<0.001). Overall profit was 2,555 ± 4,768 vs. 1,455 ± 5,638 Swiss Francs in the aLIN vs. CIRC-group, respectively (P=0.026). Conclusion This study showed improved clinical outcomes while also secondarily improving financial performance after a gradual transition from a circular stapling protocol to an augmented linear stapling protocol in proximal gastric bypass surgery. The technical transition in this study proves, that if a new technique is superior in terms of safety and postoperative morbidity, it will also be financially beneficial.

Improved Clinical and Financial Outcomes in Proximal Gastric Bypass Surgery Following the Transition from a Conventional Circular Stapling to an Augmented Linear Stapling Protocol.

Between 2011 and 2018, 454 patients were included in this retrospective study. The circular bypass protocol (CIRC; n = 177) was used between 2011 and 2012. Between 2013 and 2015 the transition occurred. Thereafter, the augmented linear protocol (aLIN; n = 277) was primarily utilized. Overall, the mean preoperative BMI dropped from 42.2 to 29.6kg/m2 after 5years with no difference between groups. Operation times were significantly shorter in the aLIN vs. CIRC group at 108 (± 32) vs. 120 (± 34) min (P < 0.001), respectively. The reoperation rate was significantly higher in the CIRC vs. aLIN group at n = 65 (36%) vs. n = 35 (13%; P < 0.001), respectively. Specifically, revision due to internal hernia occurred much more frequently in the CIRC-group, n = 36 (20%) vs. n = 12 (4%; P < 0.001). Moreover, reoperation rates for gastrojejunostomy leakage and endoscopic dilatations for anastomotic stenosis were higher in the CIRC vs. aLIN group (P < 0.001). Adjusted overall mean cost per case was lower in aLIN-patients at 15,403 (± 7848) vs. CIRC-patients at 18,525 (± 7850) Swiss francs (P < 0.001). Overall profit was 2555 ± 4768 vs. 1455 ± 5638 Swiss francs in the aLIN vs. CIRC-group, respectively (P = 0.026). This study shows improved clinical and financial outcomes after a gradual transition from a circular stapling protocol to an augmented linear stapling protocol in proximal gastric bypass surgery.

Conversion of standard Roux-en-Y gastric bypass to distal bypass for weight loss failure and metabolic syndrome: 3-year follow-up and evolution of technique to reduce nutritional complications

BackgroundStandard proximal Roux-en-Y gastric bypass (RYGB) fails to achieve long-term weight maintenance and/or control of metabolic syndrome in up to 35% of patients. ObjectivesTo improve the performance of the standard proximal gastric bypass by increasing the biliopancreatic limb length at the expense of the common channel. SettingsAcademic-affiliated private practice. MethodsA retrospective review of all patients who underwent conversion to distal RYGB from 2010 to 2016 was performed. RYGB was modified by dividing the Roux limb at the jejunojejunostomy and transposing it distally to create a shortened total alimentary limb length (TALL) of 250 to 300 cm in the initial 11 patients. Of these, 7 developed protein calorie malnutrition and diarrhea requiring a second procedure to lengthen the common channel an additional 100 to 150 cm (TALL 400–450 cm), leading to resolution of all symptoms. The subsequent 85 patients were converted to distal RYGB with TALL 400 to 450 in a single-stage operation. ResultsNinety-six RYGB patients underwent conversion to distal RYGB. The mean body mass index and mean excess weight loss at the time of distalization was 40.6 kg/m2 and 33.6%. At 1, 2, and 3 years after distalization, the mean body mass index was reduced to 34.4, 33.1, and 32.2 kg/m2, respectively, and excess weight loss improved to 41.9%, 53.7%, and 65.7%, respectively. Diabetes resolved in 66.7%, hypertension resolved in 28.6%, hyperlipidemia resolved in 40%, and sleep apnea resolved in 50% at 1 year. The 30-day complication rate and reoperation rates were 6.3% and 5.2%; an additional 7.3% (7/96) required reoperation for limb lengthening. Hypoalbuminemia developed in 21% at 3 years, but no increase in iron deficiency was observed. Calcium metabolism was affected by the distalization procedure to a greater degree as 21% of patients had low corrected calcium levels, 77% were deficient in vitamin D, and parathyroid hormone levels were above normal in 64% at 3 years. ConclusionRevision of proximal RYGB to distal RYGB results in substantial improvement in weight loss and resolution of co-morbidities at 3 years. Diarrhea and protein calorie malnutrition were seen frequently in patients with TALL of 250 to 300 cm, whereas patients with TALL 400 to 450 cm demonstrated a lower incidence of nutritional issues, but the effect on calcium, parathyroid hormone, and the fat soluble vitamins A and D is still a major concern.

Long and Narrow Gastric Pouch versus Classic Globular Pouch in Laparoscopic Proximal Gastric Bypass: Effect on Weight Loss and Dumping Syndrome

Background: Laparoscopic proximal gastric bypass Roux-en-Y (LPGBRY) has been regarded for a long time as the gold standard treatment for morbid obesity and its comorbidities. With the presence of the newer strong options, like the gastric sleeve and the mini gastric bypass, refinements in technique are taking place to avoid its current problems. Early and late gastric dumping are known problems after proximal gastric bypass. Modifications in the technique by providing the patient with a long and narrow pouch might help the problem by slowing the gastric emptying time, also should it keep the weight loss in the acceptable range. Aim: The aim of this study is to evaluate whether constructing a long and narrow pouch can decrease the incidence of early and late dumping after laparoscopic proximal gastric bypass and to evaluate the likely impact of such a long and narrow pouch on the weight loss rates. Patients and methods: The study included 79 morbidly obese patients who received primary LPGBRY for treatment of their morbid obesity. They were divided into two groups; 42 patients who received LPGBRY with a long and narrow pouch (the [LN] group), and 37 patients who received LPGBRY with a classic globular pouch (the [G] group). Their 6 and 12 months’ percentage of excess weight loss (%EWL) were recorded. Also, one year after surgery, all patients were required to fill in an Arabic translation of the Sigstad dumping score questionnaire, followed one hour later by an Arabic translation of the Arts score symptoms of late dumping, only if they scored 7 or more. Results: No significant differences were found in the %EWL between both groups. In the Sigstad questionnaire, the most commonly recorded symptoms were the need to lie down and frequent eructation, followed by dizziness, and distension. Frequent eructation was significantly higher in the [LN] group, while dizziness and palpitation were significantly more common in the [G] group (p 0.05). Half the dumping patients in group [G] had late dumping symptoms. The incidence of late symptoms in the [G] group was significantly higher than in the long and narrow pouch [LN] group (p < 0.05). Conclusion: Long and narrow pouches in LPGBRY achieve similar weight loss rates as in the classic globular pouches. Constructing a long and narrow pouch produces similar overall dumping rate, but added significantly more eructation, less dizziness, less palpitation and less late dumping symptoms when compared to the classic globular pouches.

Perioperative Outcomes of Proximal and Distal Gastric Bypass in Patients with BMI Ranged 50-60 kg/m(2)--A Double-Blind, Randomized Controlled Trial.

BackgroundProximal Roux-en-Y gastric bypass may not ensure adequate weight loss in superobese patients. Bypassing a longer segment of the small bowel may increase weight loss. The objective of the study was to compare the perioperative outcomes of laparoscopic proximal and distal gastric bypass in a double-blind randomized controlled trial of superobese patients. The study was conducted at two public tertiary care obesity centers in Norway.MethodsPatients with body mass index (BMI) 50–60 kg/m2 were randomly assigned to a proximal (150 cm alimentary limb) or a distal (150 cm common channel) gastric bypass. The biliopancreatic limb was 50 cm in both operations. Patients and follow-up personnel were blinded to the type of procedure. Thirty-day outcomes including complications are reported.ResultsWe operated on 115 patients, of whom two were excluded at surgery, leaving 56 and 57 patients in the proximal group and distal group, respectively. The median (range) operating time was 72 (36–151) and 101 (59–227) min, respectively (p < 0.001). Two distal procedures were converted to laparotomy during the primary procedure. Median length of hospital stay was 2 (1–4) days in the proximal group and 2 (1–24) days in the distal group. The number of patients with complications and complications categorized according to the Contracted Accordion classification did not differ significantly. However, all six reoperations were performed in the distal group, of which three were completed by laparoscopy (p = 0.01 between groups). There were no deaths.ConclusionsIn superobese patients with BMI between 50 and 60 kg/m2, distal gastric bypass was associated with longer operating time and more severe complications resulting in reoperation than proximal gastric bypass.

Variación del perfil cardiometabólico en pacientes diabéticos obesos intervenidos de cirugía bariátrica. Cambios en el riesgo cardiovascular

Introduction and objectivesBariatric surgery is a valuable tool for metabolic control in obese diabetic patients. The aim of this study was to determine changes in weight and carbohydrate and lipid metabolism in obese diabetic patients during the first 4 years after bariatric surgery. MethodsA retrospective study was performed in 104 patients (71 women; mean age, 53.0 [0.9] years; mean body mass index, 46.8 [0.7]) with type 2 diabetes mellitus (median duration, 3 years) who underwent laparoscopic proximal gastric bypass. ResultsBlood glucose levels and glycated hemoglobin concentrations decreased during the first 1-3 postoperative months. Values stabilized for the rest of the study period, allowing hypoglycemic treatment to be discontinued in 80% of the patients. No significant differences were observed as a function of the body mass index, diabetes mellitus duration, or previous antidiabetic treatment. Weight decreased during the first 15-24 months and slightly increased afterward. Levels of total cholesterol, triglycerides, and low-density lipoprotein significantly decreased, and target values were reached after 12 months in 80% of the patients. No correlation was found between these reductions and weight loss. Similarly, high-density lipoprotein concentrations decreased until 12 months after surgery. Although concentrations showed a subsequent slight increase, target or lower high-density lipoprotein values were achieved at 24 months postintervention in 85% of the patients. ConclusionsBariatric surgery is effective for the treatment of obese diabetic patients, contributing to their metabolic control and reducing their cardiovascular risk.Full English text available from:www.revespcardiol.org/en

Modification of Cardiometabolic Profile in Obese Diabetic Patients After Bariatric Surgery: Changes in Cardiovascular Risk

Introduction and objectivesBariatric surgery is a valuable tool for metabolic control in obese diabetic patients. The aim of this study was to determine changes in weight and carbohydrate and lipid metabolism in obese diabetic patients during the first 4 years after bariatric surgery. MethodsA retrospective study was performed in 104 patients (71 women; mean age, 53.0 [0.9] years; mean body mass index, 46.8 [0.7]) with type 2 diabetes mellitus (median duration, 3 years) who underwent laparoscopic proximal gastric bypass. ResultsBlood glucose levels and glycated hemoglobin concentrations decreased during the first 1-3 postoperative months. Values stabilized for the rest of the study period, allowing hypoglycemic treatment to be discontinued in 80% of the patients. No significant differences were observed as a function of the body mass index, diabetes mellitus duration, or previous antidiabetic treatment. Weight decreased during the first 15-24 months and slightly increased afterward. Levels of total cholesterol, triglycerides, and low-density lipoprotein significantly decreased, and target values were reached after 12 months in 80% of the patients. No correlation was found between these reductions and weight loss. Similarly, high-density lipoprotein concentrations decreased until 12 months after surgery. Although concentrations showed a subsequent slight increase, target or lower high-density lipoprotein values were achieved at 24 months postintervention in 85% of the patients. ConclusionsBariatric surgery is effective for the treatment of obese diabetic patients, contributing to their metabolic control and reducing their cardiovascular risk.

Latent Autoimmune Diabetes in Adults Presenting as Diabetes “Recurrence” After Bariatric Surgery: A Case Report

Here, we describe a novel presentation of latent autoimmune diabetes in adults (LADA) involving a deterioration of glycemic control in a patient after bariatric surgery. A 43-year-old woman with a 7-year diagnosis of type 2 diabetes (T2D), treated initially with metformin and then also insulin glargine 2 years later, and a background of hypothyroidism and vitiligo was referred for bariatric surgery. Her weight was 106 kg (maximum lifetime weight 114 kg), and BMI was 35 kg/m2. HBA1c 97 mmol/mol (11%) improved to 57 mmol/mol (7.4%) with no change in weight with addition of the glucagon-like peptide-1 (GLP-1) receptor agonist liraglutide preoperatively. After laparoscopic proximal gastric bypass (LPGB), insulin and liraglutide were discontinued. Weight loss was 29% after 6 months and 38% after 1 year; however, glycemic improvement was less than expected: HbA …

Arterioles from Bariatric Patients with Diabetes Have Blunted Responses to Insulin but not Acetylcholine

Obesity and type‐2 diabetes are associated with cardiovascular disease and endothelial dysfunction of which the mechanisms leading to aberrant insulin‐dependent vasodilation are incompletely understood. As not all obese individuals are diabetic, we hypothesize that reduced insulin‐dependent vasodilation is a specific endothelial dysfunction independent of the degree of obesity that accompanies the presence of overall insulin resistance. We tested this hypothesis in jejunal submucosal arterioles obtained from bariatric patients undergoing Roux‐en‐Y proximal gastric bypass surgery. Patients were 49±2 years old with a body mass index (BMI) of 48.5±2.4 Kg/m2. No differences in age or BMI were found between diabetics (n=22) and non‐diabetics (n=30). Maximal arteriolar responses to KCl, phenylephrine, acetylcholine, or sodium nitroprusside were not significantly different between diabetics and non‐diabetics. In contrast, insulin‐dependent vasodilation was smaller in diabetics (40.4±6.4 vs. 61.9±8.8%, respectively). This suggests that a blunted insulin‐vasodilation response is a form of endothelial dysfunction not correlated with BMI in type‐2 diabetes. The blunted‐response to insulin occurring in the absence of an abnormal acetylcholine‐induced dilation suggest that the mechanism responsible for the blunted insulin response is upstream of nitric oxide synthase activation.

Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results

Background Although gastric bypass is the most common bariatric procedure in the United States, it is has been associated with a failure rate of 15% (range 5–40%). The addition of an adjustable gastric band to Roux-en- Y gastric bypass has been reported to be a useful revision strategy in a small series of patients with inadequate weight loss after proximal gastric bypass. Methods We report on 22 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an adjustable silicone gastric band around the proximal gastric pouch. The bands were adjusted at 6 weeks postoperatively and beyond, as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Results The mean age and body mass index at revision was 41.27 years (range 25–58) and 44.8 ± 6.34 kg/m 2, respectively. Patients had experienced a loss of 19%, 27%, 47.3%, 42.3%, 43%, and 47% of their excess weight at 6, 12, 24, 36, 48, and 60 months after the revisional procedure, respectively. Three major complications occurred requiring reoperation. No band erosions have been documented. Conclusion The results from this larger series of patients have also indicated that the addition of the adjustable silicone gastric band causes significant weight loss in patients with poor weight loss outcomes after gastric bypass. That no anastomosis or change in absorption is required makes this an attractive revisional strategy. As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation.

Can glucose make you faint?

In April, 2008, a 27-year-old woman came to the emergency department of her local hospital, with a 3-week history of dizziness, low appetite, and occasional vomiting. 2 months before, she had undergone an uncomplicated laparoscopic proximal gastric bypass for obesity; on discharge, she was prescribed multivitamins and lansoprazole.

PL-57: Adjustable gastric banding as a revisional bariatric procedure after failed gastric bypass - intermediate results

Although gastric bypass is the most common bariatric procedure in the United States but it is has been associated with a failure rate of 15% (5-40%). The addition of adjustable gastric banding to Roux en Y gastric bypass has been reported to be a useful revision strategy in a small series of patients with inadequate weight loss after proximal gastric bypass.

Gastro-ileal Stenosis and Gastroparesis after a Biliopancreatic Diversion

Biliopancreatic diversion (BPD) is a very effective bariatric operation particularly for super-obese patients (BMI > or = 50 kg/m(2)). We present the development of a stricture at the gastro-ileal anastomotic site, with subsequent dilatation and aperistalsis of the stomach in a female patient who had undergone a standard open Scopinaro BPD. The patient remained symptomatic and persisted in losing weight, despite endoscopic balloon dilatations of the stricture and surgical revision of the anastomosis. She finally underwent conversion to a standard Roux-en-Y proximal gastric bypass. We describe the development of the stricture after the use of the stapling gun, subsequent gastric dilatation and dysmotility.

Bowel Obstruction after Open and Laparoscopic Gastric Bypass Surgery for Morbid Obesity

Bowel obstruction is increasingly recognized as an important complication after gastric bypass. This study analyzed late bowel obstruction after open and laparoscopic gastric bypass surgery. The medical records of 1,378 patients who had proximal gastric bypass during the years 2002 and 2003 at a large bariatric center were evaluated for readmission with bowel obstruction requiring operations. In the study group, 697 patients underwent a laparoscopic approach and 735 had an open approach to gastric bypass. Patients had a minimum followup of 18 months. In the laparoscopic group, 68 of the 697 patients were readmitted for bowel obstruction requiring operations, for an incidence of 9.7%. There were 14 additional recurrent obstructions, for a total of 82 operations. Of the 68 patients requiring reoperations, 3 (4.4%) required bowel resection and 8 (11.7%) had conversion to an open approach. Bowel resections were performed in two of the three patients with a second episode of bowel obstruction. The average time intervals between the primary operation in 2002 and 2003 and the first episode of obstruction were 511 and 385 days, respectively. There were no readmissions requiring operations for late bowel obstruction in the open gastric bypass group. We found an unanticipated high incidence of bowel obstruction after laparoscopic gastric bypass surgery. There were no hospital admissions for bowel obstruction requiring operations in the open gastric bypass group. Lack of adhesions and the resulting free displacement of small bowel after laparoscopy appear to be the cause of this complication. Open gastric bypass surgery produces thin, diffuse upper abdominal adhesions that may then stabilize the bowel and prevent internal hernias and bowel obstruction. An open approach may be a reasonable option for management of recurrent episodes of bowel obstruction after laparoscopy.

Adjustable Gastric Banding as a Revisional Bariatric Procedure after Failed Gastric Bypass

Inadequate weight loss after proximal gastric bypass presents a clinical challenge to bariatric surgeons. Pouch size, stoma size and limb length are the variables that can be surgically altered. Aside from conversion to distal bypass, which may have significant negative nutritional sequelae, revisional surgery for this group of patients has not often been reported. The addition of adjustable silicone gastric banding (ASGB) to Roux-en-Y gastric bypass (RYGBP) may be a useful revision strategy because it has potential safety benefits over other revisional approaches. We report on 8 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an ASGB around the proximal gastric pouch. Bands were adjusted at 6 weeks postoperatively and beyond as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Mean age and body mass index (BMI) at the time of revision were 39 +/- 9.9 years and 44.0 +/- 4.5 kg/m2 respectively. No patients were lost to follow-up, and they lost an average of 38.1 +/- 10.4% and 44.0 +/- 36.3% of excess weight and 49.1 +/- 20.9% and 52.0 +/- 46.0% of excess BMI in 12 and 24 months respectively. Patients lost an average of 62.0 +/- 20.5% of excess weight from the combined surgeries in 67 (48-84) months. The only complication was the development of a seroma overlying the area of the port adjustment in one patient. There have been no erosions or band slippages to date. These results indicate that the addition of an ASGB causes significant weight loss in patients with poor weight loss outcome after RYGBP. The fact that no anastomosis or change in absorption is required may make this an attractive revisional strategy. Long- term evaluation in a larger population is warranted.

Topical Benzocaine (Hurricaine®) Induced Methemoglobinemia during Endoscopic Procedures in Gastric Bypass Patients

Methemoglobinemia results from oxidation of ferrous to ferric iron in hemoglobin. In addition to a functional anemia, methhemoglobinemia causes the O2-binding affinity of the remaining O2 sites in the hemoglobin tetramer to increase; essentially shifting the oxyhemoglobin dissociation curve to the left and decreasing O2 delivery. Patients develop profound cyanosis unresponsive to O2 when methemoglobin (MHb) levels exceed 10%. It can be lethal if levels exceed 70%. Benzocaine 20% (Hurricaine) spray, commonly used in endoscopy (EGD) can cause methemoglobinemia. We report our experience. Two patients out of >1,000 EGDs in 4 yrs developed methemoglobinemia. Patient 1: 34 F, BMI 46, open distal gastric bypass. Patient 2: 26 F, BMI 49, laparoscopic proximal gastric bypass. Both had nausea and vomiting from stomal stenosis requiring EGD for which benzocaine 20% spray was used. Severe cyanosis (despite pulse oximetry readings of 86% and 89%), dyspnea and tachycardia, were seen within 13 and 7 minutes. They were unresponsive to O2, despite being awake and conversant after complete reversal of sedatives. MHb levels were 35.6% and 18.8% (normal <1%). Patients dramatically improved after 1% methylene blue at 1-2 mg/kg IV over 5 minutes. MHb levels dropped to 2.3% and 0.8 % within 150 and 110 minutes. Neither patient had any evidence of pulmonary embolism or DVT or G6PD deficiency. Topical benzocaine 20% (Hurricaine) spray used in EGDs gets absorbed and can cause methemoglobinemia. Sprays should be limited to 1 second. Prompt treatment with 1% methylene blue IV can be life-saving.

Cirugía bariátrica laparoscópica: bypass gástrico proximal

The spectacular increase in the prevalence of obesity in our society and the significant complications and comorbidities that it gives rise to have stimulated the interest of scientists and public in this pathology. Surgical treatment is at present the only efficient and lasting treatment for morbid obesity and in many cases it appreciably improves, and even definitively cures, associated complications such as the case of diabetes or hypertension. Amongst the different techniques of bariatric surgery, the gastric bypass (GBP) seems to be definitively establishing itself, since it offers an excellent balance between loss of weight (>70% of the excess), surgical risk and subsequent quality of life. The possibility of carrying out this technique employing a laparoscopic approach has improved its acceptance by doctors and patients while it has made it possible to reduce morbidity and mortality, length of hospital stay and costs. Proximal GBP is carried on those patients with an BMI <60 Kg/m2; for BMI >60 Kg/m2 the GBP employed is denominated distal. Between October 2003 and November 2005, our centre performed 55 laparoscopic proximal Roux-en-Y gastric bypasses via laparoscopy. These involved 42 women and 13 males with an average age of 44 years. The average BMI was 43.5 (35-55.8). The average basal weight was 116.15 Kg. There was no peroperative mortality, nor reinterventions. The BMI after 12 months was 28.4. The average basal weight was 74.2 Kg. Laparoscopic Roux-en-Y proximal gastric bypass is a safe and efficient technique for the treatment of morbid obesity.