Proximal Gastric Pouch Research Articles

Correction of body weight regain after Roux-en-Y gastric bypass. Clinical case

Obesity and overweight are health problems that indicate excessive and abnormal accumulation of body fat and lead to adverse health effects. Epidemiological studies have identified obesity and overweight as risk factors for several diseases, including diabetes, various cancers, cardiovascular disease, and hypertension. Roux‑en‑Y gastric bypass is one of the most common operations performed for the patients with morbid obesity. With the long‑term follow‑up of bariatric surgery, insufficient weight loss or weight regain is becoming more frequently encountered after RYGB. Insufficient weight loss or weight regain after proximal Roux‑en‑Y gastric bypass occurs in 35% of cases. As a result, revisional surgery will be more frequently performed. No consensus has been reached on the best revisional operation for these patients. The presented clinical case demonstrates tactical approaches to a comprehensive examination of patients who are scheduled for revision surgery due to insufficient weight loss or weight regain after Roux‑en‑Y gastric bypass. 3D computer gastrovolumetry is an effective method that allows the qualitative and quantitative examination of the state of the proximal gastric pouch after Roux‑en‑Y gastric bypass. The presented clinical case demonstrates the importance of an individualized approach for each patient, according to the recommendations of the multidisciplinary team for diagnosis and correct surgical strategy treatment weight regain after Roux‑en‑Y gastric bypass. Combined reconstruction of the gastric pouch with gastroenteroanastomosis and distalization of the alimentary loop is a safe and effective method of correction of weight regain in patients after Roux‑en‑Y gastric bypass.

GASTROESOPHAGEAL SYMPTOMS AFTER LAPAROSCOPIC GASTRIC BYPASS: MISTAKES IN PERFORMING THE PROCEDURE?

ABSTRACT - BACKGROUND:Laparoscopic Roux-en-Y gastric bypass (LGB) is the recommended procedure for morbidly obese patients with gastroesophageal reflux disease (GERD). However, there have been reported gastroesophageal reflux symptoms or esophagitis after LGB. Few functional esophageal studies have been reported to date.AIM: To evaluate the anatomic and physiologic factors contributing to the appearance of these problems in patients who underwent LGB.METHODS: This prospective study included 38 patients with postoperative gastroesophageal reflux symptoms submitted to LGB. They were subjected to clinical, endoscopic, radiologic, manometric, and 24-h pH-monitoring evaluations.RESULTS: Eighteen (47.4%) of 38 patients presented with heartburn or regurgitation, 7 presented with pain, and 4 presented with dysphagia. Erosive esophagitis was observed in 11 (28.9%) patients, and Barrett’s esophagus (5.7%) and jejunitis (10.5%) were also observed. Hiatal hernia was the most frequent finding observed in 15 (39.5%) patients, and most (10.5%) of these patients appeared with concomitant anastomotic strictures. A long blind jejunal loop was detected in one (2.6%) patient. Nearly 75% of the patients had hypotensive lower esophageal sphincter (9.61±4.05 mmHg), 17.4% had hypomotility of the esophageal body, and 64.7% had pathologic acid reflux (% time pH <4=6.98±5.5; DeMeester’s score=32.4±21.15).CONCLUSION: Although rare, it is possible to observe gastroesophageal reflux and other important postoperative symptoms after LGB, which are associated with anatomic and physiologic abnormalities at the esophagogastric junction and proximal gastric pouch.

Successful revision surgery for very late-onset stomal obstruction following Gomez gastroplasty: a case report

BackgroundGomez gastroplasty, which was developed in the 1970s as one of the gastric restrictive surgeries for severe obesity, partitions the stomach using a stapler from the lesser towards the greater curvature at the upper gastric body, leaving a small channel. This procedure is no longer performed due to poor outcomes, but surgeons can encounter late-onset complications even decades after the surgery. Here, we report a case of very late-onset stomal obstruction following Gomez gastroplasty which was successfully treated by revision surgery.Case presentationA 58-year-old man was referred to our institution with sudden-onset nausea and vomiting. He underwent weight loss surgery in the USA in 1979, but the details of the surgery were unclear. Esophagogastroduodenoscopy demonstrated a stoma at the greater curvature of the upper gastric body, and fluoroscopy showed retention of contrast medium in the fundus and poor outflow through the stoma. Abdominal computed tomography revealed a staple line partitioning the stomach. Considering these preoperative investigation findings and the period during which the surgery was performed, the patient was diagnosed with very late-onset stomal obstruction following Gomez gastroplasty. Supporting the preoperative diagnosis, the surgical findings revealed a staple line extending from the lesser towards the greater curvature of the upper gastric body and a channel reinforced by a running seromuscular suture on the greater curvature. Moreover, gastric torsion caused by the enlarged proximal gastric pouch was found. Re-gastroplasty involving wedge resection of the original channel was performed followed by construction of a new channel. Postoperative course was uneventful, and the patient no longer had symptoms of stomal obstruction after revision surgery.ConclusionsRe-gastroplasty was safe and feasible for very late-onset stomal obstruction following Gomez gastroplasty. Accurate preoperative diagnosis based on the patient’s interview and the investigation findings was important for surgical planning. A careful follow-up is required to prevent excessive weight regain after revision surgery.

Spontaneous Gastrogastric Fistulalization After Being Left in Discontinuity of Proximal Gastric Pouch and Roux Limb Due to Catastrophic Gastrojejunal Marginal Ulcer Perforation

Spontaneous Gastrogastric Fistulalization After Being Left in Discontinuity of Proximal Gastric Pouch and Roux Limb Due to Catastrophic Gastrojejunal Marginal Ulcer Perforation

2201 Innovative Endoscopic Management of a Bariatric Surgery Complication

INTRODUCTION: Vertical Banded gastroplasty (VBG) is a purely restrictive bariatric surgery that was the predominant weight loss procedure in the 1980s. The following case describes a well-known complication of VBG that was managed with an innovative endoscopic technique. CASE DESCRIPTION/METHODS: A 56-year-old lady with a history of open VBG 18 years ago presented with several years of recurrent vomiting, heartburn, and excessive weight loss. An upper GI series revealed a large distend proximal gastric pouch above the mesh with severe stasis that produced a mass effect and resultant compression of the rest of the stomach. She was offered a conversion to Roux en y gastric bypass, however she declined. She was subsequently referred to a GI for further evaluation and potential endoscopic intervention. An Upper GI endoscopy was performed, which revealed mild esophagitis, evidence of vertical banded gastroplasty, and gastric pouch distention with copious amount of food debris. The lumen through the band was identified and was noted to be very narrowed and was not easily traversable with the upper endoscope. Therefore, a decision was made to perform an EUS guided gastro-gastrostomy with placement of a lumen opposing metal stent. The distal pouch was punctured under EUS guidance and a 15 × 10 mm AXIOS Stent was deployed adjacent to the previously placed band, creating a larger lumen for food content to pass. The stent was serially dilated to 18 mm using a through the scope (TTS) dilator. Contrast injected proximally was seen to flow freely from the gastric pouch into the antrum and the duodenum through the stent. Patient had an uneventful post-procedure course and was discharged the next day. She later reported significant improvement in reflux symptoms, gained 15 pounds, and was more than elated. DISCUSSION: VBG quickly gained popularity in the 1980s because it was the only bariatric surgery that did not have malabsorptive side effects. Over time, however, patients began experiencing post procedural nausea, vomiting, and heartburn from pouch dilatation, band erosion, staple line disruption, marginal ulceration, and is now rarely used as a bariatric surgical option. The versatility of endoscopic stents have made them useful in the management of many bariatric surgical complications, including fistulas, leaks, obstructions, strictures, and stenoses. To our knowledge, this was the first case of severely symptomatic pouch dilatation following VBG that was successfully managed endoscopically.

The Effect of Gastric Bypass with a Distal Gastric Pouch on Glucose Tolerance and Diabetes Remission in Type 2 Diabetes Sprague-Dawley Rat Model.

Gastric bypass with a proximal gastric pouch (Roux-en-Y gastric bypass) induces early diabetes remission. The effect of gastric bypass with a distal gastric pouch remains unknown. To observe the effect on glucose tolerance and diabetes remission of gastric bypass with a distal gastric pouch. A type 2 diabetes (T2D) model was created in 44 Sprague-Dawley (SD) rats that randomly underwent Roux-en-Y gastric bypass (RYGB, n = 8); gastric bypass with duodenal-jejunal transit (GB-DJT, n = 8); distal-pouch gastric bypass with duodenal-jejunal transit (DPGB-DJT, n = 8); distal-pouch gastric bypass with duodenal-jejunal bypass (DPGB-DJB, n = 8); sham (n = 6); and Roux-en-Y gastric bypass with esophageal re-anastomosis (RYGB-Er, n = 6) surgery. In the DPGB-DJT and the DPGB-DJB groups, the gastric pouch was created in the distal stomach. In the RYGB and the GB-DJT groups, the gastric pouch was created in the proximal stomach. An oral glucose tolerance test (OGTT), insulin tolerance test (ITT) and mixed-meal tolerance test (MMTT) conducted preoperatively were repeated postoperatively. GLP-1 AUC recorded preoperatively was significantly increased 8weeks postoperatively in the RYGB, GB-DJT, and DPGB-DJB groups. Increased GLP-1 AUC in the DPGB-DJT did not reach statistical significance. Improved glucose tolerance in the RYGB and GB-DJT groups was significantly higher than DPGB-DJT group. DPGB-DJB did not improve glucose tolerance significantly. Gastrin level was increased significantly in the DPGB-DJT and DPGB-DJB groups. In gastric bypass, creating the gastric pouch in the distal region of the stomach significantly impairs the glucose tolerance and diabetes remission in spite of the increased GLP-1 and insulin responses in T2D SD rat model, suggesting that bypassing the distal stomach may be the key mediator of early diabetes remission after RYGB.

A139 - Gastrogastric Fistula and Type 2 Diabetes: Can Fistula Closure Improve Diabetes?

Roux-en-Y gastric bypass (RYGB) has been shown to significantly improve glucose control in patients with type 2 diabetes. A gastrogastric fistula (GGF) is defined as a communication between the proximal gastric pouch and the distal gastric remnant following RYGB. The formation of a GGF allows nutrients to pass through the native route, rather than bypassing the duodenum in typical RYGB configuration. Patients with GGF can present with weight regain and recurrence of diabetes. We sought to evaluate the effect of revisional bariatric surgery for known GGF on control of diabetes.

Laparoscopic Gastric Bypass Revision

Gastrogastric fistula is a rare complication following a roux-en-y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy. Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. Here, we present a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation.

Banded Roux-en-Y gastric bypass for the treatment of morbid obesity

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective treatment for morbid obesity. The additional benefit of placing a nonadjustable band around the pouch remains to be determined. The objective of this study was to compare outcomes between banded and nonbanded LRYGB patients in a single bariatric center. MethodsA matched cohort analysis was performed between patients who had undergone banded and nonbanded (standard) LRYGB. In the banded bypass cohort, an 8 F, 6.5 cm silastic ring was placed around the proximal gastric pouch. Both cohorts were matched for age, body mass index (BMI), and anastomotic technique. Endpoints included percentage excess weight loss (%EWL), postoperative morbidity, and band-related complications. ResultsBetween January 2007 and July 2010, 134 banded LRYGB were performed (55% female, mean age 45 years). They were compared with a matched cohort of 134 concurrent nonbanded LRYGB patients (67% female, mean age 45.4 years). Mean preoperative BMI was 54.6 and 52.8 kg/m2, respectively (P = .084). At 24 months postoperatively, the average %EWL was 58.6% in banded bypass patients and 51.4% in the nonbanded group (P = .015). The difference in EWL was more pronounced in super-obese patients than in those with BMI<50 (among super-obese, 57.5% versus 47.6%, P = .003; among those with BMI<50, 62.9% versus 57.9%, P = .406]. There was no difference in early (19.4% versus 19.4%) or late complications (10.4% versus 13.4%, P = .451) between banded and nonbanded LRYGB patients. ConclusionBanding the pouch during LRYGB can be performed safely and may provide better weight loss, particularly in super-obese patients. Further prospective and long-term comparative studies of this technique are warranted.

Risk of Gastric Pouch Enlargement With Adjustable Gastric Banding in Premenopausal Women

To examine the influence of age and gender on the development of proximal gastric pouch distension (PPD) after laparoscopic adjustable gastric banding (LAGB) surgery. PPD is the most common reason for revision with adjustable gastric banding surgery. Maintaining the anatomical integrity of bariatric surgery is a key to long-term success. It is therefore important to understand risk factors for complications. We extracted details of 3000 consecutive individuals who underwent primary LAGB procedures at a single center between February 2005 and May 2011. Contemporaneous details of all complications were recorded in a database. The characteristics of those that subsequently required revision surgery for PPD were assessed and compared with those that did not. There were 132 cases for PPD requiring surgical intervention before September 2011. Incident PPD occurred in 5.1% and 1.3% of women and men, respectively. The mean age of those with PPD was 39.9 ± 9.25 compared with 43.9 ± 11.0 for those without it. The age and gender effects were independent, and the age effect was restricted to women. The adjusted odds ratios were 0.971 (95% CI [confidence interval], 0.954-0.986, P < 0.001) for age and 0.26 (95% CI, 0.12-0.56, P = 0.001) for male gender and younger women were more likely to have asymmetrical distension. Younger women are at higher risk of PPD after LAGB surgery than men and women older than 50 years. Sex hormones may play a role in predisposing to gastric stretch after surgery. These findings may apply more broadly to the gastric "restrictive" component of other bariatric procedures.

Emerging causes of iron deficiency anemia refractory to oral iron supplementation

While oral iron supplementation is commonly used throughout many clinical setting, treatment with intravenous (IV) iron has historically been reserved for specific settings, such as chronic kidney disease, gynecologic issues, and anemia associated with cancer and its treatments. However, the use of IV iron has begun to gain popularity in the treatment of iron deficiency anemia (IDA) associated with two conditions that are being seen more frequently than in years past: patients who are status post gastric bypass procedure and those with inflammatory bowel disease (IBD). The Roux-en-Y procedure involves connecting a gastric pouch to the jejunum, creating a blind loop consisting of distal stomach, duodenum, and proximal jejunum that connects to the Roux limb to form a common tract. IDA occurs in 6%-50% of patients who have undergone a gastric bypass, the etiology being multifactorial. The proximal gastric pouch, the primary site of gastric acid secretion, is bypassed, resulting in a decreased ability to metabolize molecular iron. Once metabolized, most iron is absorbed in the duodenum, which is entirely bypassed. After undergoing bypass procedures, most patients significantly limit their intake of red meat, another factor contributing to post-bypass IDA. Chronic anemia occurs in approximately 1/3 of patients who suffer from IBD, and almost half of all IBD patients are iron deficient. IBD leads to IDA through multiple mechanisms, including chronic intestinal blood loss, decreased absorption capabilities of the duodenum secondary to inflammation, and an inability of many IBD patients to tolerate the side effects of oral ferrous sulfate. In this study, we reviewed the charts of all patients who received IV iron at Sylvester Comprehensive Cancer Center/University of Miami Hospital Clinic from January 2007 to May 2012. The most common indications for IV iron were for issues related to cancer and its treatment (21.9%), IBD (20.1%), and gastric bypass (15.0%). Of the 262 patients who received IV iron, 230 received iron sucrose and 36 received iron dextran. While doses of 100, 200, 300, and 400 mg of iron sucrose were given, 100 and 200 mg were by far the most common dosages used, 122 and 120 times, respectively. The number of dosages of iron sucrose given ranged from 1 to 46, with a mean of 5.5 and a median of 4 doses. The average dose of iron dextran given was 870.5 mg, with 1000 mg being the most common dosage used. Most patients (22 of 36) who received iron dextran only received one dose. While patients with traditional indications for IV iron, such as gynecologic issues and kidney disease, still were represented in this study, we expect to see a continued increase in physicians using IV iron for emerging gastrointestinal indications, especially considering the increased safety of new low-molecular formulations.

Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy

Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents (SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwent a computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.

Exploration of esophageal hiatus: does crural repair reduce proximal pouch distension?

BackgroundRepair of a hiatal hernia during laparoscopic adjustable gastric banding is advisable; however, the practice of more active esophageal hiatus exploration and repair has been promoted with an expectation of reducing proximal gastric pouch distension (PPD). Our objective was to explore the relationship between crural exploration and repair (CR) and PPD in a private practice in Canada. MethodsThe data from 3000 consecutive patients who underwent primary laparoscopic adjustable banding procedures at a single center from February 2005 to May 2011 were examined. Several analyses were performed, with the PPD cases carefully matched to historic (time-of-placement) and historic-, age-, and gender-matched controls. ResultsThroughout the series, the PPD rates decreased and the CR rates increased. Revision for PPD was performed in 132 patients (4.4%). The patients with PPD were more likely to have undergone CR during primary surgery (odds ratio 1.5, 95% confidence interval 1.2–2.2, P = .001) compared with historic, and historic-, age-, and gender-matched controls (odds ratio 2.3, 95% confidence interval 1.4–3.8, P < .001). The findings were confirmed using adjusted binary logistic regression analysis controlling for age, gender, body mass index, and time-of-placement. This increased risk was most evident early in the series when incident PPD cases were greater. However, at no stage did CR reduce the risk of symmetric or asymmetric PPD. ConclusionThe results of the present analysis do not support the theory that increased exploration and repair of the esophageal hiatus reduces the incidence of PPD. There might be a role for CR at surgery for specific clinical indications. CR increases the complexity and possibly the risk of the procedure.

Long-term results of adjustable gastric banding in a cohort of 186 super-obese patients with a BMI ≥ 50 kg/m2

There are conflicting results concerning the bariatric effectiveness of adjustable gastric banding in super-obese patients with a Body Mass Index (BMI) more or equal to 50 kg/m(2). A cohort of 186 patients with a BMI greater or equal to 50 kg/m(2) who underwent adjustable gastric banding (AGB) at the Bichat-Claude-Bernard University Hospital (Paris, France) were prospectively entered into a database. The following data were recorded: BMI, percentage of BMI loss, percentage of excess weight lost (%EWL), complications, and surgical re-interventions. Loss of greater than 50% of excess weight was considered a success (primary endpoint). A %EWL of less than 25% after one year, or the removal of the gastric band was considered a failure. Thirty-five men (18.8%) and 151 women (81.2%), with a mean age of 38.9 years (range: 16-65) underwent AGB between September 1995 and December 2007. The mean BMI was 55.06 kg/m(2) (range: 50-74.4). Mean follow-up was 112.5 months with a minimum of 28 months and a maximum of 172 months. The follow-up rate was maintained at 89% at ten years. The technique of AGB was by "peri-gastric dissection" in the first 115 patients (61.82%) and by "pars flaccida dissection" in 71 patients (38.17%). The gastric band was removed in 87 of 186 patients (46.8%); band ablation was due to a complication of the gastric band in 62 of these cases (33.3%), to failure of weight loss in 23 cases (12.4%), and to patient request in two cases (1%). The major complications requiring re-operation were: chronic dilatation of the proximal gastric pouch (27 patients - 14.5%), acute dilatation (21 patients - 11.3%), intragastric migration of the prosthesis (six patients - 3.2%), reflux esophagitis (six patients - 3.2%), infection of the gastric band (one patient - 0.5%), and Barrett's esophagus (one patient - 0.5%). No statistically significant difference was found between the two operative techniques with regard to the possibility of preserving the gastric band for ten years. For patients who underwent band removal, no further follow-up analysis of patient data after band ablation was performed. The results were best at two years after AGB with a median BMI of 42.72 kg/m(2), a band removal rate of 8.6% (16 of 186 patients), and a failure rate of 16.4% (28 of 170 patients) of those patients who still had their band in place. However, at 10 years, the picture was completely reversed with a band removal rate of 52.2% (47 of 90 patients), a failure rate of 22% (seven of 33 patients) of those who still had their band in place, and a median BMI of 43.43 kg/m(2). Laparoscopic gastroplasty using the adjustable gastric band appeared to be a promising intervention for super-obese patients when the results at two years were analyzed - fairly simple to perform, with perioperative morbidity and mortality near zero. However, these results do not persist in the long-term for super-obese patients. At ten years, only 11% of patients (nine of 80) have successful bariatric results (%EWL>50%) and we were forced to remove the gastric band in 52.2% of patients (47 of 90) because of complications, regardless of the initial operative technique used. Given these results, AGB gastroplasty is not a recommended method for super-obese patients and we believe that a BMI greater or equal to 50 kg/m(2) is a contra-indication for this procedure.

Pregnancy May Increase the Risk of Proximal Gastric Pouch Dilatation after LAGB Surgery

Interpretation of data: Finding no difference is not the same as reassuring us that there isn't one! It is all a matter of confidence. Pregnancy after bariatric surgery is an important topic and one in which we have had a great interest. We have published widely on the outcomes of laparoscopic adjustable gastric banding (LAGB) surgery including two manuscripts specifically on pregnancy and birth outcomes [3, 4]. These provided significant new insights into the management of the band during pregnancy. We have an issue with the interpretation of the data and subsequent conclusion of the manuscript by Rebecca Haward and colleagues, titled “Does pregnancy increase the need for revisional surgery after laparoscopic adjustable gastric banding?” [6]. The authors conclude that it is unlikely that pregnancy has an effect on the need for LAGB revisions. We believe that the data presented does not support this conclusion. The data signals concern that pregnancy may increase the risk of proximal pouch dilatation (PPD) and need for revisional surgery. We have also shared the authors' concern that pregnancy with an LAGB in situ could increase the risk of PPD having observed pregnant women who sometimes reported the onset of obstructive symptoms during pregnancy which continued thereafter, and subsequently required revisional surgery for PPD. Our hypothesis was that the profound changes to smooth muscle, including that of the upper gastrointestinal tract, which are largely hormonally driven and occur during pregnancy [1, 5, 7], may lead to an increased risk of stretching or dilatation of the proximal stomach and /or lower esophagus in the gravid state. Other commonly used bariatric surgical procedures, including Roux-en Y gastric bypass and sleeve gastrectomy, also rely on the stability of the anatomical changes just below the gastroesophageal junction; hence, they may also be at risk of abnormal stretching or dilatation that may occur during pregnancy. Haward et al. set an arbitrary level of concern at a surgical revision rate that is 60% greater in the pregnancy group than in a matched control group. That is if the reoperation rate was greater than a 60% increase or a hazard ratio >1.6, this would signal an increased risk. Showing no significant difference between groups cannot reassure us that there is not an increased risk. To demonstrate that there is no meaningful increased risk, at their elected level, the upper 95% confidence interval (CI) of the hazard ratio should be at or below 1.6. The authors report a hazard ratio for primary revision of the band in the pregnancy group at 3 years of 1.7 with a CI of 0.9 to 3.3. For PPD, we calculate from their data an odds ratio of 1.9 with a CI of 0.9 to 4.1 (Table 3, p=0.08). While the study did not find a definite statistically significant increase in revisional surgery in those that had a pregnancy, it did not reassure us that there was no increase in risk, with both ratios above 1.6 and upper CIs well above the 1.6 level set by the authors for a signal of increased risk. Clearly, the power of the study was J. B. Dixon :M. E. Dixon Obesity Research Unit, Department of General Practice, Monash University, Melbourne, Australia

Nutrient absorption, feed intake and liveweight change as a consequence of Roux-en-Y gastric bypass with increasing alimentary limb lengths in the pig model

Roux-en Y gastric bypass (RYGBP) combines a restrictive and malabsortive component of the digestive system. Metabolic outcomes of increasing the latter, is a matter of research interest. The aim of this study was to evaluate the nutritional consequences of RYGBP with different alimentary limb lengths using a pig model. Twenty-six pigs were randomly assigned to four laparoscopic procedures: RYGBP with 300 cm of alimentary limb (T300); RYGBP with 600 cm (T600); RYGBP with 900 cm (T900); sham operation (TS). RYGBP consisted of creating a proximal gastric pouch with a 300, 600 and 900 cm alimentary limb. Sham operation was performed by bowel transections and reanastomosis in the ileum and proximal jejunum together with gastrotomy and closure. Animals were evaluated weekly for weight increase and monthly for food intake. Eighteen weeks after surgery, fecal in vivo apparent digestibility of protein, fat, fiber, calcium and phosphorous were determined. We performed ANOVA and Tukey tests to detect differences in weight, feed intake and digestibility. We observed significant differences in liveweight after 10 weeks among T300, T600 and T900 as compared to TS. No differences were found among T300, T600 and T900. We also observed significant differences in feed intake among T300, T600 and T900 versus TS. No differences among treatments for digestibility of fat; fiber; protein and energy were found. Calcium and phosphorous apparent digestibility differed among treatments. RYGBP reduced weight increase in the porcine model and calcium and phosphorous digestibility was reduced with longer limbs.

Long-term results of malabsorptive distal Roux-en- Y gastric bypass in superobese patients

Background The purpose of the present study was to evaluate the safety, efficacy, and nutritional outcomes of malabsorptive distal Roux-en- Y gastric bypass (D-RYGB) 20–25 years later at a university hospital. Methods From 1985 to 1989, 49 mostly superobese (body mass index >50 kg/m 2) patients had undergone D-RYGB. D-RYGB consisted of open laparotomy with a 50-mL proximal gastric pouch and gastroenterostomy performed 250 cm proximal to the ileocecal junction, with common channels of 50–150 cm. These 49 patients were compared with a similar group of 92 consecutive patients who had undergone long-limb RYGB, with a 75-cm biliopancreatic limb and 150-cm alimentary limb. Results The mean ± SD preoperative body mass index was 58.9 ± 9.3 kg/m 2. After 1 perioperative death secondary to pulmonary embolism, limb-lengthening revisions were required in 21 (43.7%) of the 48 remaining patients for protein-calorie malnutrition. Of the 23 with a 50-cm common channel, 13 required revision compared with 8 of 25 with ≥100-cm common channel ( P <.05, chi-square). Of the 48 patients who had undergone D-RYGB, 8 had died 6–19 years after D-RYGB. Of the nonrevised patients, 19 (70.4%) of 27 had >5 years of follow-up. In these, the latest body mass index was 34.2 kg/m 2 at 10 ± 6.1 years. The percentage of excess weight loss was 66.8% ± 14%. The lowest late serum albumin level was 3.4 ± .5 g/dL (range 2.3–4.4). The mean 25-hydroxy vitamin D level was 14.6 ± 11.3 ng/mL. Compared with patients who had undergone long-limb RYGB, the D-RYGB patients had a significantly greater percentage of excess weight loss after 5 years but significantly lower albumin, hemoglobin, iron, and calcium levels. Conclusion Although D-RYGB afforded superior long-term weight loss, it caused protein-calorie malnutrition requiring frequent revision. The nonrevised patients had frequent severe metabolic derangements. Thus, D-RYGB should not be the primary operation for morbid or superobese patients.

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.

The Use of Seamguard® to Buttress the Suture Repair of a Staple Line Leak Following Laparoscopic Gastric Bypass for Obesity

Anastomotic and staple line leak following laparoscopic gastric bypass are recognised complications with significant mortality and morbidity. Several techniques have been described to reduce the incidence of staple line leaks, including reinforcement of staple lines using omental wraps, fibrin glue, and Peristrips and Seamguard. Using a similar principle, we describe a case report of the successful use of a Seamguard buttress in the repair of a staple line leak at the proximal gastric pouch following laparoscopic gastric bypass. The repair of the leak was confirmed by gastrogaffin contrast study as well as clinically as the patient progressed well in the postoperative period. Ten months following surgery, her weight had reduced from 125 kg (BMI 47.6 kg/m(2)) to 82.4 kg (BMI of 31.4 kg/m(2)). We suggest that surgeons facing similar problems may choose to employ this novel technique.

Symmetrical Pouch Dilatation After Laparoscopic Adjustable Gastric Banding: Incidence and Management

Laparoscopic adjustable gastric banding (LAGB) has commonly been complicated by the problem of band slippage or prolapse. Since popularization of the pars flaccida approach and improved anterior fixation, it is our impression that the problem of symmetrical dilatation of the proximal gastric pouch has become more important. We have reviewed the results of a series of 425 LAGB all performed by the pars flaccida approach from June 2003 to October 2007 to analyze the incidence and implications of this new pattern. There were no posterior prolapses, 2 anterior prolapses, and 17 cases of symmetrical pouch dilatation (SPD) (revision rate 4.4%). Teenage patients had a 22% revision rate for SPD. All revisions were completed laparoscopically with no mortality, no significant complications, and a median hospital stay of 1 day. The median weight loss following revisional surgery was not significantly different from the background cohort. SPD is the most common reason for revision of LAGB in this series. We postulate that SPD is caused by excessive pressure in the proximal gastric pouch. This may be generated either by eating too quickly or too large a volume or excessive tightening of the band. The radial forces in the pouch may ultimately cause pressure on the phrenoesophageal ligament and a secondary hiatal hernia.