Roux-en-Y Gastric Bypass Patient Research Articles

IBC-Oxford University2023_BJSPoster_11Early Results and Postoperative Complications in Bariatric International Centers of Reference for Weight Loss Surgery

Abstract Background Metabolic/Bariatric Surgery (MBS) is worldwide recognized as the best treatment option for obesity. Medical insurance restrictions, better financing conditions and social media easy access make persons with obesity look for international centers of reference to make possible their access to weight loss surgery. These kinds of surgeries are frequently performed in Tijuana, Baja California, Mexico, where there are dedicated specialized high-volume hospital centres. Like any major surgery, bariatric procedures are not exempt from complications, which need to be considered and adequately treated as they can compromise the patient's well-being. Will be presented here the early results and complications from 4 centres of excellence as part of Baja California College of Bariatric and Metabolic Surgeons. Methods This is an observational, descriptive, and retrospective study based on medical records of patients who underwent primary MBS in specialized high-volume hospital centres in Tijuana, Baja California, Mexico, from March to September 2022. The following information of interest will be collected: age, gender, comorbidities, BMI, type of surgery performed, surgical time, length of stay, trans/postoperative complications, and hospital readmission in a 30-day postoperative observational time. Once the data collection process is completed, a descriptive analysis will be conducted using SPSS version 26 software for MacOS. Means and standard deviations will be obtained for quantitative variables, while frequencies and percentages will be calculated for qualitative variables. Results A total of 3906 patients were included, with 85.8% being female and 14.2% being male. The average weight and BMI in females and males were 113.6 kg and 138.8 kg, and 42.3 kg/m2 and 44.7 kg/m2, respectively. Hypertension was reports in 961 individuals (31%), while 383 reported type-2 diabetes (12%). Sleeve gastrectomy (LSG) was performed in 90% of the patients, 5.1% were Roux-en-Y gastric bypass (RYGB), and 3.6% were one anastomosis gastric bypass (OAGB). The average surgical time per procedure was 59 minutes in general with 40 (± 9) min, 94 (± 19) min and 70 (± 27) min respectively for LSG, RYGB and OAGB. A total of 15 patients (0.38%) experienced some form of early postoperative complication, with the majority (8 cases) being postoperative bleeding. Additionally, there were 4 leaks, 1 sleeve migration, 1 sleeve obstruction, and 1 intestinal obstruction. Out of these, 13 patients (0.33%) required a surgical reintervention before discharge (7 cases of bleeding, 4 cases of leaks, sleeve migration, and sleeve obstruction). 12 out of the 13 reinterventions occurred following sleeve gastrectomy, while the remaining reintervention was a result of intestinal obstruction in a RYGB patient. Length of stay varies from 2 to 4 days with an average of 2.2 days. Conclusion Complications are very low in international MBS centres of excellence in Tijuana, Mexico. The experience and skill of the bariatric surgeon are directly related to the number of surgeries performed in their professional practice, which, in turn, helps prevent the occurrence of short-term postoperative complications and to allow the early diagnosis and prompt treatment adoption.

Intussusception of the jejuno-jejunal anastomosis in a patient with Roux-en-Y gastric bypass

Intussusception is a rare complication in postoperative patients undergoing Roux-en-Y gastric bypass (RYGB), with an incidence of 0.64%. The clinical presentation usually involves severe abdominal pain, accompanied by nausea and vomiting. The diagnostic approach using imaging studies involves computed tomography, revealing the radiological "target" sign. The treatment is surgical, with the lowest recurrence rate (12.5%) observed in the resection and anastomosis of the intussuscepted segment. The objective is to present the case of intussusception at the jejuno-jejunal anastomosis in a postoperative RYGB patient, along with its therapeutic approach, in a hospital in northern Mexico.

Volume-outcome relationships for Roux-en-Y gastric bypass patients in the sleeve gastrectomy era.

Sleeve gastrectomy is now the most common bariatric operation performed. With lower volumes of Roux-en-Y gastric bypass (RYGB), it is unclear whether decreasing surgeon experience has led to worsening outcomes for this procedure. We used State Inpatient Databases from Florida, Iowa, New York, and Washington. Bariatric surgeons were designated as those who performed ten or more bariatric procedures yearly. Patients who had RYGB were included in our analysis. Using multi-level logistic regression, we examined whether surgeon average yearly RYGB volume was associated with RYGB patient 30-day complications, reoperations, and readmissions and 1-year revisions and readmissions. From 2013 to 2017 there were 27,714 patients who underwent laparoscopic RYGB by 311 surgeons. Median surgeon volume was 77 RYGBs per year. The distribution was 10 bypasses yearly at the 5th percentile, 16 bypasses at the 10th percentile, 38 bypasses at the 25th percentile, and 133 bypasses at the 75th percentile. Multi-level regression revealed that patients of surgeons with lower RYGB volumes had small but statistically significant increased risks of 30-day complications and 1-year readmissions. At 30days, risk for any complication was 6.71%, 6.43%, and 5.55% at 10, 38, and 133 bypasses per year, respectively (p = 0.01). Risk for readmission at 1year was 13.90%, 13.67%, and 12.90% at 10, 38, and 133 bypasses per year, respectively (p = 0.099). Of note, volume associations with complications and reoperations due to hemorrhage and leak were not statistically significant. There was also no significant association with revisions. This is the first study to examine the association of surgeon RYGB volume with patient outcomes as the national experience with RYGB diminishes. Overall, surgeon RYGB volume does not appear to have a large effect on patient outcomes. Thus, patients can safely pursue RYGB in this early phase of the sleeve gastrectomy era.

A Matched Cohort Comparison of Long-term Outcomes of Roux-en-Y Gastric Bypass (RYGB) Versus Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S).

The long-term effectiveness of Roux-en-Y gastric bypass (RYGB) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is unknown. Compare the long-term outcomes. Single private institute, USA. Data from 1254 patients who underwent primary RYGB or SADI-S were used for a retrospective matched cohort. Data were obtained by matching every RYGB patient to a SADI-S patient of the same sex, body mass index (BMI), and weight. Only patients out 5years and had at least one > 5-year follow-up visit were included. The matched cohort included 61 RYGB and 61 SADI-S patients. There was no statistical, demographic difference between the two groups. At 5years, a 100% follow-up was available in each group. The intraoperative outcomes were significantly better with SADI-S. The 30-day readmission, reoperation, emergency department (ED) visits, and complication rates were statistically similar between the two groups. The long-term complication rates, Clavien-Dindo grade IIIb complications, and number of patients with more than one complication were significantly lower with SADI-S. Weight loss was significantly greater in the SADI-S group at 5years. The long-term weight-loss failure rate was significantly higher in the RYGB group. The SADI-S procedure was associated with fewer reintervention through 6years (14.7% patients vs. 39.3% patients, p = 0.001). Conversion or reversal of the procedure was required only in the RYGB group. There also was no significant difference in nutritional outcomes between the two procedures. This study showed that problems, including long-term complications, reinterventions, weight-loss failure, and conversion, were more often associated with RYGB than with SADI-S. The SADI-S may be considered one of the viable alternatives to RYGB.

Internal EUS-Directed Transgastric ERCP (EDGE): Game Over

s the prevalence of obesity in the United States Aexceeds 30%, the number of bariatric procedures being performed, including Roux-en-Y gastric bypass (RYGB), is steadily increasing. Therefore, gastroenterologists will inevitably be required to manage pancreaticobiliary diseases in more patients with altered anatomy. Various techniques including deep enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopy-assisted ERCP have been developed to address the anatomic challenges of these patients. However, they are not without their limitations. Technical success rates of enteroscopy-assisted ERCP have been reported to be as low as 63% in multicenter trials. Alternatively, whereas laparoscopy-assisted ERCP has high technical success rates, it carries significant risk of complications and is more costly. Therefore, efforts by endoscopists have been focused on gaining endoscopic access to the excluded stomach to perform conventional antegrade ERCP. A recently published case series described using deep enteroscopy to achieve gastrostomy access. Our group has recently published a technique utilizing endoscopic ultrasonography (EUS) to gain gastrostomy access, but was performed in 2 stages. The procedure was coined EUSdirected transgastric ERCP (EDGE). The ideal procedure would be one that can be performed by a single team, with a high technical success rate, in a single session, in a minimally invasive fashion. With the recent Food and Drug Administration approval of a novel, fully covered, lumen-apposing metal stent (AXIOS; XLumena, Mountain View, CA) this procedure is now possible. This case report describes the first entirely endoscopic internal EDGE procedure using a lumenapposing metal stent to create a gastrogastric fistula in a RYGB patient to perform single-session antegrade ERCP.

Bariatric surgery-mediated weight loss and its metabolic consequences for type-2 diabetes

The worldwide epidemic of obesity and its medical complications are being dealt with a combination of life style changes (e.g., healthier diet and exercise), medications and a variety of surgical interventions. The Roux-en Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are two of the most common weight loss surgeries for morbid obesity-associated metabolic syndrome and insulin resistance. A vast majority of patients that undergo RYGB and LAGB are known to experience marked weight loss and attenuation of diabetes. A number of recent studies have indicated that the rates of remission in glycemic control and insulin sensitivity are significantly greater in patients that have undergone RYGB. A plausible hypothesis to explain this observation is that the gastric bypass surgery as opposed to the gastric banding procedure impinges on glucose homeostasis by a weight loss-independent mechanism. In a recent paper, Bradley et al have experimentally explored this hypothesis. The authors compared several clinical and laboratory parameters of insulin sensitivity and β-cell function in cohorts of RYGB and LAGB patients before and after they lost approximately 20% of their body mass. After weight loss, both groups of patients underwent similar changes in their intra-abdominal and total adipose tissue volume, hepatic triglyceride and circulating leptin levels. The RYGB patients who lost 20% body mass, manifested higher postprandial output of glucose, insulin and glucagon-like peptide-1; these laboratory parameters remained unchanged in LABG patients. Irrespective of the observed differences in transient responses of RYGB and LAGB patients to mixed meal, the overall glycemic control as judged by glucose tolerance, multi-organ insulin sensitivity and β-cell function were nearly identical in the two groups. Both RYGB and LAGB patient cohorts also experienced similar changes in the expression of a number of pro- and anti-inflammatory markers. Based on these analyses, Bradley et al concluded that similar restoration of insulin sensitivity and b-cell function in non-diabetic obese patients that have undergone RYGB and LAGB were directly due to marked weight loss. These data have important implications for the risk/benefit analysis of weight loss therapy by bariatric procedures.

Pharmacokinetic considerations in Roux-en-Y gastric bypass patients

Pharmacokinetic considerations in patients who have undergone Roux-en-Y gastric bypass (RYGB) are explored. The prevalence of obesity, especially morbid obesity, has dramatically increased in recent years. In response, the number of bariatric surgeries performed has risen sharply, as this surgery is the technique demonstrated as being the most effective for sustained treatment of morbid obesity. RYGB, the most popular technique in the United States, combines the principle of restriction (dramatically decreasing stomach size) with malabsorption (bypassing the entire duodenum). It stands to reason that a decrease in gastric and intestinal absorptive surface area may considerably affect oral bioavailability of some drugs. Drugs that require a more acidic environment for absorption, uncoating, or activation and drugs that rely on intestinal transporters located in the duodenum for proper absorption would be most affected. Practitioners looking for guidance in tailoring pharmacotherapy to the RYGB patient will find little help in the primary literature at this time. Until more pharmacokinetic studies are available, practitioners may apply and log P of individual the principles of pK(a) drugs in the attempt to predict the potential impact of the RYGB on a drug's absorption. Likewise, if a drug relies on certain transporters located with highest frequency in the duodenum, alternative therapies can be selected that do not rely on such transport mechanisms for absorption. The pK(a), log P, and intestinal transport mechanisms should be considered when determining which drugs may have altered pharmacokinetics in patients who have undergone RYGB.

Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m2)

BackgroundCurrently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m2). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.MethodsIn a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.ResultsBetween November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.ConclusionTo the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

Clinical Presentation of Beriberi After Roux-en-Y Gastric Bypass (RYGB) Surgery

Purpose: RYGB is the most common surgical procedure performed for medically-complicated obesity. We previously reported a high prevalence of thiamine deficiency associated with small intestinal bacterial overgrowth (SIBO) after RYGB (Nutrition Res, 2008). Clinical manifestations of Beriberi include: 1) Neuropsychiatric; 2) High output cardiovascular disease (wet Beriberi); 3) Neurological/Neuropathies (dry Beriberi); or 4) Gastrointestinal (nausea/emesis/megajejunum or constipation/megacolon). The purpose of this study is to estimate the prevalence of and subtypes of Beriberi after RYGB. Methods: Prospective study performed in an urban community hospital. Consecutive RYGB patients seen at a new joint Medical/Surgical Bariatric Clinic from February 1, 2008 to May 1, 2009 were included in this study. Data included date of and type (open or laparoscopic) of RYGB, sex, age, thiamine diphosphate levels, Beriberi symptoms (Types 1-4), thiamine supplementation, and potential resolution with thiamine treatment. Beriberi is defined in this study by: 1) consistent clinical symptoms and examination and 2) either low blood thiamine level (n=22), or resolution of consistent clinical symptoms after intramuscular (IM) thiamine (n=5). Results: Of 151 patients evaluated, 25 females and 2 males met the criteria for Beriberi (estimated prevalence of 18%); age range is 30-68 years (mean age: 50 years); 4 patients had laparoscopic while 23 had open RYGB. Symptoms were noted 2 months to 9 years (mean: 5.0 years) after RYGB. In these 27 RYGB patients, 12 have one symptom consistent with Beriberi while 15 have symptoms consistent with multiple subtypes. Among these patients, 52% had Type 1 Beriberi, 67% had Type 2, 11% had Type 3, and 48% had Type 4 (GI) Beriberi. Of 20 patients with symptoms of Beriberi prior to treatment with IM thiamine, all 20 (100%) noted post-treatment symptomatic improvement. In 3 patients, a symptom of Beriberi returned after replacing IM thiamine therapy with oral thiamine supplements. Conclusion: In our patient population, a high prevalence of Beriberi was identified on average 5.0 years after RYGB. The most common Beriberi identified was Type 2 (wet Beriberi). General gastroenterologists are seeing an increasing number of bariatric patients. For symptoms of nausea, emesis or constipation, GI Beriberi should be considered. However, other types of Beriberi may be present. Oral thiamine alone may be an ineffective treatment in these patients, supporting malabsorption. If there is a clinical suspicion of Beriberi in a RYGB patient, therapy with IM thiamine should be started. Further studies are required to determine whether treating SIBO in RYGB patient prevents Beriberi or may be effective as an adjuvant therapy in patients with Beriberi.

Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope

Background: Successful per-oral ERCP has been reported in long-limb surgical bypass patients, including Roux-en-Y cases, using standard push enteroscopes (Howell, GIE 1996;43: 383AB). Newer bypass procedures have resulted in increased length of bypass limbs preventing endoscopic access with standard equipment. The single-balloon overtube assisted enteroscope (SBAE)(Olympus America) has recently been released. We report initial experience performing per-oral ERCP using SBAE. Patients and Methods: 10 procedures were attempted in 8 pts, with the following long-limb bypasses: Pylorus preserving Whipple (PPW) (n=2) and bariatric laparoscopic Roux-en-Y gastric bypass (RNYGB) (n=8). Four pts (2 PPW and 2 RNYGB) had a previous failed attempt with other endoscopes, including variable stiffness colonoscopes and standard-push enteroscopes with non-balloon overtubes. Indications: All procedures were carried out with the new Olympus Q180 200cm SBAE. Cannulation and therapy was performed with special enteroscope length accessories supplied by various companies. Indications included: common duct stone (n=1), ampullary stenosis/SOD Type I (n=1), recurrent pancreatitis (n=2), severe right upper quadrant (RUQ) pain with dilated ducts (n=2), chronic pancreatitis (n=2), and PD stent removal (n=2). Results: 8/10 (80%) procedures were successful in reaching the RUQ and assessing the desired duct. Two failures were due to adhesions in one PPW patient and inability to advance beyond the ligament of Treitz in a RNYGB patient. Two diagnostic ERCPs noted a normal cholangiogram in one and extensive pyloric channel ulcer disease in the other. Six therapeutic ERCPs included biliary sphincterotomy (n=1), pancreatic sphincterotomy with stent placement (n=2), biductal sphincterotomy with nasopancreatic drainage (n=1), and pancreatic stent removal (n=2). Complications included a single episode of delayed mild pancreatitis. Both barbless pancreatic duct stents failed to pass after 3 weeks requiring a second SBAE ERCP with successful removal. Experience is ongoing. Conclusions: Single-balloon assisted enteroscopy permitted access to the RUQ in most patients in this initial experience. Diagnostic and therapeutic ERCP was accomplished in all cases where the RUQ was reached. Technical challenges include the front-viewing nature of the enteroscope, the absence of an elevator and the limited selection of therapeutic accessories. Routine per oral ERCP in post-operative long-limb bypass patients should be routinely possible, at least in specialized centers of excellence.

Nausea, Bloating and Abdominal Pain in the Roux-en-Y Gastric Bypass Patient: More Questions than Answers

Bariatric surgery is the most effective treatment for severe obesity. After surgery, patients may complain of gastrointestinal symptoms but their altered anatomy can make investigations difficult to perform or interpret. In particular, the Roux-en-Y gastric bypass (RYGBP) creates an excluded segment that is not easily accessible. We present a case illustrating some of the difficulties encountered when investigating the RYGBP patient complaining of nonspecific GI symptoms. Options are discussed for examining the excluded segment, and the diagnosis and significance of small intestine bacterial overgrowth in the RYGBP patient is reviewed.

True Fractional Calcium Absorption is Decreased After Roux‐En‐Y Gastric Bypass Surgery

Roux-en-Y gastric bypass (RYGB) is considered to be the gold standard alternative treatment for severe obesity. Weight loss after RYGB results primarily from decreased food intake. Inadequate calcium (Ca) intake and metabolic bone disease can occur after gastric bypass. To our knowledge, whether malabsorption of Ca contributes to an altered Ca metabolism in the RYGB patient has not been addressed previously. We recruited 25 extremely obese women in order to study true fractional Ca absorption (TFCA) before and 6 months after RYGB surgery, using a dual stable isotope method ((42)Ca and (43)Ca) and test load of Ca (200 mg). Hormones regulating Ca absorption and markers of bone turnover were also measured. In 21 women (BMI 52.7 +/- 8.3 kg/m(2), age 43.9 +/- 10.4 years) who successfully completed the study, TFCA decreased from 0.36 +/- 0.08 to 0.24 +/- 0.09 (p < 0.001) after RYGB. Bone turnover markers increased significantly (p < 0.01). TFCA correlated with estradiol levels (r = 0.512, p < 0.02) and tended to correlate with 1,25 (OH)(2)D (r = 0.427, p < 0.06) at final measurement. Stepwise linear regression indicated that estradiol explained 62% of the variance for TFCA at 6 months post-surgery (p < 0.01). TFCA decreases (0.12 +/- 0.08) after RYGB surgery but remains within normal range. Although only some patients were estimated to have low Ca absorption after surgery, all of the patients showed a dramatic increase in markers of bone resorption. The alteration in Ca metabolism after RYGB-induced weight loss appears to be regulated primarily by estradiol levels and might ultimately affect bone mass.

Dissolution of Common Psychiatric Medications in a Roux-en-Y Gastric Bypass Model

Large numbers of Roux-en-Y gastric bypass (RYGB) surgery patients have psychiatric illnesses that are in part treated with medication preoperatively, but there are no objective data to guide psychiatric drug dosing postoperatively. An in vitro drug dissolution model was developed to approximate the gastrointestinal environment of the preoperative (control) and post-RYGB states. Medication tablets were placed in the two environments, and the median calculated weights of the dissolved portions were compared. Ten of 22 psychiatric medication preparations had significantly less dissolution and two had significantly greater dissolution in the post-RYGB environment, compared with the control environment. The results suggest a need for an in vivo study of serum drug levels after RYGB surgery in patients taking psychiatric medications. Differences in the pharmacokinetics of the postoperative RYGB patient may necessitate adjustments in dosing.

Assessment of routine elimination of postoperative nasogastric decompression after Roux-en-Y gastric bypass

Background. Anastomotic disruption after surgical intervention is an infrequent complication, but may lead to severe morbidity and mortality when it occurs. Of the various gastric procedures, the Roux-en-Y gastric bypass (RYGB) has one of the highest risks for anastomotic leakage. Consequently, a nasogastric tube (NGT) is frequently placed when these operations are performed. Most studies examining the outcomes for patients without postoperative NGTs have been relatively small with groups of patients undergoing a variety of operations. Assessing the incidence of anastomotic leaks by routine elimination of postoperative NGTs requires a large number of patients. In this study, we assessed the safety and efficacy of routine elimination of NGTs in a large cohort of patients undergoing a single operation. Methods. We reviewed our experience with 1067 patients who underwent RYGB at the UCLA medical center. Fifty-six patients had NGTs routinely placed before the implementation of a standard protocol, which eliminated postoperative NGT decompression. The complication rate for the RYGB patient cohort with and without postoperative NGT was compared. Results. We found no difference in the complication rates between the 2 groups (Fisher exact test; P =.21). Conclusions. Our findings suggest that routine placement of an NGT after RYGB is unnecessary. (Surgery 2002;132:844-8.)

Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients.

Marginal ulceration (MU) after Roux-en-Y gastric bypass (RYGB) is a well-recognized complication. Its incidence varies between 1% and 16%. Factors associated with the development of MU include pouch size, pouch orientation, staple line integrity, and mucosal ischemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori may also contribute to MU, but their mechanism of action in the RYGB patient has not been studied. In 1994 a prospective 3-year study was designed to document the incidence of MU after near-total gastric bypass (NTGB). In this procedure the transected pouch was limited to the cardia, and the gastrojejunostomy was made along the greater curvature. A total of 173 patients entered the study. All patients who experienced postoperative nausea, vomiting, or abdominal pain underwent endoscopic examination of the pouch, stoma, and proximal Roux-en-Y limb. Gastrograffin studies were used within the first 2 weeks of operation. One year after operation, MU was not identified in any patient. At 3 years follow-up, MU was documented in one patient (0.6%) with a dilated gastric reservoir (60 cc). This study reviews the etiology, diagnosis, and treatment of MU in the RYGB patient and offers specific recommendations to reduce its occurrence. It also confirms a preliminary impression that NTGB is an effective operation in preventing MU formation.