Roux-en-Y Gastric Bypass For Morbid Obesity Research Articles

Is the Current Micronutrient Supplementation Adequate in Preventing Deficiencies in Indian Patients? Short- and Mid-Term Comparison of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

Bariatric procedures reduce the capacity of the gut and alter the gastrointestinal transit time predisposing to micro-nutritional deficiencies. This study analyzed and compared the micro-nutritional parameters following laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) in the Indian population. This is a retrospective study of patients who underwent LSG or RYGB for morbid obesity at a tertiary care center between January 2015 and December 2016. The micronutrient parameters, namely, serum ferritin, vitamin B12, ionized calcium, vitamin D3, and parathormone (PTH) in the preoperative settings and subsequently at 1, 2, and 3years were analyzed. A total of 390 patients were studied, of which 258 (66.15%) underwent LSG while 132 (33.85%) underwent RYGB. Baseline micronutrient parameters were comparable in the two groups. Anemia (58.1% vs. 59.1%), deficiencies of ferritin (31.7% vs. 34.3%), vitamin B12 (18.8% vs. 36.4%), ionized calcium (65.1% vs. 72.7%), vitamin D3 (95.3% vs. 90.9%), and secondary hyperparathyroidism (45.5% vs. 58.1%) were seen following LSG and RYGB at the end of 3years, respectively. There was no significant difference found between LSG and RYGB in terms of micronutrient deficiencies studied, including rising in PTH at 1, 2, and 3years. Vitamin D3 levels were significantly lower at 2 and 3years following RYGB (p = 0.035 and p = 0.032, respectively). LSG and RYGB have comparable micronutrient deficiencies in the short- and mid-term except for vitamin D3, which is higher following RYGB. Long-term studies are needed to define optimum micronutrient supplement dosages for the Indian population.

Laparoscopic Heller myotomy after Roux-en-Y gastric bypass

Achalasia is a rare motility disorder of the esophagus and laparoscopic Heller myotomy (LHM) is the standard of care for symptom relief. The onset of achalasia in obese patients after Roux-en-Y gastric bypass (RYGB) is rare, the diagnosis is difficult, and the treatment is challenging. We reviewed the hospital charts of a patient presenting with achalasia after RYGB. A review of the pertinent literature was performed. A 51-year-old female was admitted to our department for a 10-month history of progressive dysphagia, regurgitation, and weight loss. She previously underwent laparoscopic RYGB for morbid obesity. The upper gastrointestinal endoscopy showed a dilated esophagus with increased resistance at the gastroesophageal junction. The barium swallow study revealed the classical “mouse-tail” appearance of the esophagogastric junction with delayed esophageal emptying. High-resolution manometry (HRM) was suggestive of a type II achalasia with esophageal body pan-pressurization. The patient underwent LHM. The overall operative time was 95 min and intraoperative blood loss was negligible. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 24-month follow-up, the patient has complete remission of symptoms. Development of achalasia in obese patients after RYGB is rare. The presence of pathognomonic symptoms should always raise clinical suspicion, while HRM is essential to confirm the diagnosis. To date, there is no robust evidence for the more appropriate treatment of esophageal achalasia after RYGB. In these patients, LHM seems feasible, safe, and effective in symptom relief.

Risk factors for early postoperative complications after bariatric surgery.

PurposeVertical sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are currently the most common bariatric procedures. Although the safety of these operations has markedly improved, there continues to be a certain rate of complications. Such adverse events can have a significant deleterious effect on the outcome of these procedures and represent a costly burden on patients and society at large. A better understanding of these complications and their predictive factors may help ameliorate and optimize outcomes.MethodsSeven hundred seventy-two consecutive patients who underwent SG or RYGB for morbid obesity between January 2011 and October 2015, in the Division of Bariatric Surgery at a tertiary institution, were included through retrospective review of the medical database. The complications were categorized and evaluated according to severity using the Clavien-Dindo classification system. Significant risk factors were evaluated by binary logistic regression to identify independent predictors and analyzed to identify their relationship with the type of complication.ResultsIndependent predictors of severe complication after these procedures included male gender, open and revisional surgery, hypertension, and hypoalbuminemia. Hypoalbuminemia had significant associations with occurrence of deep surgical site infection and leak. Open surgery had significant associations with occurrence of superficial and deep surgical site infection and respiratory complications. Independent predictors of severe complication after laparoscopic primary RYGB included previous abdominal surgery. Previous abdominal surgery had significant associations with deep surgical site infection and leak.ConclusionRecognition and optimization of these risk factors would be valuable in operative risk prediction before bariatric surgery.

Surgical Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass: 10-Year Experience.

Gastrogastric fistula (GGF) occurs in 1-6% of patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia, fistula, or ulcer. The purposes of the study are to describe the principles of management and to review the literature of this uncommon complication. The setting of this study is University Hospital, France. We conducted a retrospective review of all patients' records with a diagnosis of GGF after RYGB between January 2004 and November 2014. During the study period, 1273 patients had RYGB for morbid obesity. Fifteen patients presented with a symptomatic GGF (1.18%). The average interval from surgery to presentation was 28months (22-62). A history of marginal ulcer or anastomotic leak was present in nine patients (60%). The most common presentation was weight regain (80%), followed by pain (73.3%). Two types of fistulas were identified, an exclusively GGF (high) and a gastro-jejuno-gastric fistula (low). High GGF, frequently associated with dilatation of the gastric pouch, was treated by a sleeve of the pouch and sleeve resection of the remnant stomach (nine patients). Low GGF was treated with gastric resection coupled with a revision of the gastrojejunal anastomosis (six patients). All patients were treated laparoscopically with no conversion to laparotomy. The average length of postoperative hospital stay was 5.2days (range 3-10). GGF after RYGB is a rare complication. Its pathophysiology remains unclear. Surgical management is the definitive treatment.

Management of Injury to the Common Bile Duct in a Patient with Roux-en-Y Gastric Bypass.

Introduction. Most surgeons prefer Roux-en-Y hepaticojejunostomy (RYHJ) for biliary reconstruction following a common bile duct (CBD) injury. However, in patients with a Roux-en-Y gastric bypass (RYGB) a RYHJ may be technically challenging and can interfere with bowel physiology induced by RYGB. The use of a hepaticoduodenostomy (HD) resolves both these issues. Presentation of Case. We present a case of CBD injury during laparoscopic cholecystectomy one year after laparoscopic RYGB for morbid obesity. Due to adhesions and previous surgery with RYGB, we did not want to interfere with the RYGB physiology by anastomosing the CBD to the jejunum or ileum. Succeeding a full Kocher's maneuver we performed biliary reconstruction by a tension-free end-to-side HD. The postoperative recovery was uneventful and the patient was discharged after eight days. At four-month follow-up, the patient had stable weight and normal laboratory test results. MRCP demonstrated normal intra- and extrahepatic bile ducts with status after HD. Discussion. We propose that HD should be considered in treatment of CBD injury in post-RYGB patients as it may reduce the risk of interfering with the post-RYGB physiology.

Postprandial Proximal Gastric Acid Pocket in Patients after Roux-En-Y Gastric Bypass

IntroductionAn unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in normal individuals and patients with gastroesophageal reflux disease (GERD). The role of gastric anatomy in the physiology of the PPGAP remains unclear. It is also unclear whether operations that control GERD, such as Roux-en-Y gastric bypass (RYGB) and Nissen fundoplication, change the PPGAP. AimsThis study aims to analyze the presence of PPGAP in patients submitted to RYGB. MethodsFifteen patients who had a RYGB for morbid obesity (mean age 53 years, 14 females, mean time from operation 3 years) were studied. All patients were free of foregut symptoms. Patients underwent a high-resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES). A station pull-through pH monitoring was performed from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal (40 g of chocolate, 50% fat). ResultsAcidity was not detected in the stomach of four patients before meal. After meal, PPGAP was not found in eight patients. In three patients, a PPGAP was noted with an extension of 1 to 3 cm. ConclusionPPGAP is present in a minority of patients after RYGB; this finding may explain part of the GERD control after RYGB and that the gastric fundus may play a role in the genesis of the PPGAP.

Aerobic endurance training improves weight loss, body composition, and co-morbidities in patients after laparoscopic Roux-en- Y gastric bypass

Background One of the most effective treatments of patients with morbid obesity is laparoscopic Roux-en- Y gastric bypass (RYGB). Sudden weight loss after RYGB for morbid obesity can result in a concurrent decrease in the lean body mass. However, the long-term results (weight reduction and reduced co-morbidities) depend on the postoperative long-term therapy. Aerobic physical exercise (APE) has been considered conservative treatment of obesity and type 2 diabetes mellitus. The aim of the present study was to assess the efficacy of APE on weight loss, body composition, and co-morbidities in patients after laparoscopic RYGB. The study was performed at a university hospital in Germany. Methods A total of 60 consecutive morbidly obese patients underwent laparoscopic RYGB. The patients were prospectively randomized into a low-exercise group (APE 1 time for 1 hr/wk) or a multiple-exercise group (APE 2 times for 1 hr/wk). The following prospective data were collected: age, gender, length of hospital stay, operative details, co-morbidities, postoperative complications, initial body weight and height, postoperative weight, and body composition. The patients' body composition was assessed every 8 weeks during the 24-month follow-up period. Results The average body mass index (52 kg/m 2) and other baseline characteristics were distributed equally in the 2 groups. No major complications and no significant differences in the minor complications were found postoperatively between the 2 groups. The multiple exercise group had a significantly more rapid reduction of body mass index, excess weight loss, and fat mass compared with the low-exercise group. The initial loss of body cell mass and lean body mass was significantly lower in the multiple exercise group and was regained more rapidly in the low-exercise group. In addition, the multiple exercise group showed significantly earlier resolution or improvement of co-morbidities. Conclusion APE positively influenced weight loss, body composition, and co-morbidity resolution after RYGB for obesity. Additional controlled studies and longer follow-up are needed to confirm these positive findings.

Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: Evaluation of Leak into Excluded Stomach with Upper Gastrointestinal Examination

To retrospectively evaluate the imaging features at upper gastrointestinal (GI) examination of leak into the excluded part of the stomach after the Roux-en-Y gastric bypass (RYGB) procedure and to determine the associated complications and consequences of acute versus delayed leak development. The institutional review board approved this HIPAA-compliant study; the need for informed consent was waived. Database review revealed 1655 upper GI studies performed over 6 years in 1282 patients after an RYGB procedure. Leak into the excluded stomach was diagnosed in 48 patients (39 women, nine men; age range, 29-62 years; mean age, 46 years); these patients formed our study group. Studies were analyzed by two radiologists in consensus for extent and pattern of leak into the excluded stomach and the presence of associated complications of extraluminal leak or fistula, obstruction, and acute distention of the excluded stomach. Chart review was performed to determine clinical course, treatment, associated complications, and outcome. Patients were divided into two categories on the basis of acute versus delayed development of leak into the excluded stomach. Acute leak into the excluded stomach was diagnosed within 2 months of surgery. Delayed leak occurred more than 2 months after surgery. Leak into the excluded stomach occurred in the acute postoperative period (within 2 months) in 25 of the 48 patients (52%) and was associated with extraluminal leak in 22 of those 25 patients (88%). Acute leak into the excluded stomach healed in seven of the 25 patients (28%). Delayed postoperative leak into the excluded stomach occurred in 23 of the 48 patients (48%) and resulted in failed weight loss in 14 of those 23 patients (61%). Fourteen of the 48 patients (29%) underwent surgical revision for leak into the excluded stomach. Leak into the excluded stomach was identified on upper GI studies in 48 of 1282 patients (3.7%) after RYGB for morbid obesity. Acute leak into the excluded stomach may heal spontaneously; however, remote postoperative leak into the excluded stomach can result in failed weight loss and subsequent failure of the RYGB procedure.

Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: Evaluation of Postoperative Extraluminal Leaks with Upper Gastrointestinal Series

To retrospectively evaluate the radiographic features of extraluminal leak after Roux-en-Y gastric bypass (RYGBP) surgery at upper gastrointestinal (GI) examinations in a large series of patients and to determine morbidity and mortality in those patients with leak. The investigational review board approved this HIPAA-compliant study, and the need for patient informed consent was waived. Radiologic database review revealed 1202 upper GI studies performed over a 4-year period in 906 patients after RYGBP. Extraluminal leak was identified in 50 patients. Two patients with leaks that occurred before the study period were excluded. Of the remaining 48 patients, 12 were men and 36 were women (mean age, 45 years; range, 26-64 years). Surgery had been laparoscopic in 23 patients and open in 25. Upper GI studies were analyzed by two radiologists in consensus for the origin, extent, and severity of leaks and associated findings. Chart review was performed to determine clinical course, treatment, and outcome. Fifty extraluminal leaks were detected in 48 of 904 patients (5.3%) at upper GI examinations. All leaks were identified within 28 days, and, in 37 of 48 patients (77%), leakage was diagnosed within 1 week of surgery. The majority of leaks (n = 37) originated from the gastrojejunal anastomosis. Leaks also occurred at the distal portion of the esophagus (n = 5), the gastric pouch (n = 5), the oversewn jejunum (n = 2), and the distal anastomosis (n = 1). Leaks extended into the left upper quadrant in 30 patients. Obstruction or ileus was present in 35 of 48 patients (73%). Leak into the excluded stomach was observed in 15 of 48 patients. The occurrence of extraluminal leak prolonged hospital stays; organ failure occurred in 14 (29%) and death in three (6%) of the 48 patients. Extraluminal leak was identified on upper GI series in 48 of 904 patients (5.3%) after RYGBP for morbid obesity. Extraluminal leak most commonly arises from the gastrojejunal anastomosis and extends into the left upper quadrant. Extraluminal leak affects morbidity and mortality.

Preoperative factors predictive of complicated postoperative management after Roux-en-Y gastric bypass for morbid obesity.

This study was undertaken to determine preoperative predictive factors of complicated postoperative management after Roux-en-Y gastric bypass (RYGB) for morbid obesity. Between January 1999 and January 2002, 158 patients who underwent a RYGB received a standardized preoperative evaluation and data were collected prospectively. Complicated postoperative management was defined as patients requiring postoperative ICU admission for > or =48 h, or those needing transfer from the floor to the ICU. Patients with complicated management were compared with those in whom ICU admission was not necessary. Twenty-three patients (14.5%) required prolonged ICU admission (mean stay of 6.3 +/- 1.7 days). After multivariate analysis, body mass index (BMI) >50 kg/m2, forced expiratory volume (FEV1) <80% predicted, previous abdominal surgeries, and abnormal EKG were found to be independently associated with an increased likelihood of complicated postoperative care. BMI >50 kg/m2, FEV1 <80% predicted, previous abdominal surgeries, and abnormal EKG increase the likelihood of complicated postoperative management after RYGB for morbid obesity.