The role of total alimentary limb length in Roux-en-Y gastric bypass: a systematic review.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an established surgical treatment for obesity. Variations in limb length during RYGB procedures have been investigated for optimizing weight loss while minimizing nutritional deficiencies. The role of the total alimentary limb length (TALL; Roux limb plus common channel [CC]), however, is poorly defined. OBJECTIVE: Compare TALL in RYGB procedures for weight loss outcomes and malnutrition. SETTING: Systematic review. METHODS: Ovid Medline and PubMed databases were searched for entries between 1993 and 2020. Search terms included "gastric bypass" and "TALL." Two independent reviewers screened the results. RESULTS: A total of 21 studies measured TALL in RYGB. Of these, 4 of 6 reported a relationship between TALL and weight loss. Additionally, 11 studies reported that when TALL was ≤400 cm and CC <200 cm, 3.4% to 63.6% of patients required limb lengthening for protein malnutrition. CONCLUSIONS: The majority of studies on RYGB do not report TALL length. There is some evidence that weight loss is affected by shortening TALL, while a TALL ≤400 cm with CC<200 should be avoided due to severe protein malnutrition. More studies on the effect of TALL are needed.

Gastrojejunal Anastomotic Stricture Following Roux-en-Y Gastric Bypass: an Analysis of Anastomotic Technique at a Single Institution.

PURPOSE: Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25 mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture. METHODS: We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA. RESULTS: In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS). CONCLUSION: The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures.

Impacts of Gastrojejunal Anastomotic Technique on Rates of Marginal Ulcer Formation and Anastomotic Bleeding Following Roux-en-Y Gastric Bypass.

BACKGROUND: Marginal ulceration (MU) and bleeding are possible complications following laparoscopic Roux-en-Y gastric bypass (RYGB). Our institution utilizes three techniques for performing the gastrojejunal anastomosis (GJA), providing a means to compare postoperative MU and bleeding as it relates to GJA technique. OBJECTIVES: We sought to analyze the incidence of MU and bleeding between the 25-mm end-to-end anastomosis (EEA) stapler, linear stapler (LS), and robotic hand-sewn (RHS) GJA techniques. METHODS: Electronic health records for all patients who had an upper endoscopy (EGD) after RYGB were queried (2010-2014). Charts were retrospectively reviewed for type of GJA, complications, endoscopic interventions, and smoking and NSAID use. RESULTS: Out of 1112 RYGBs, the GJA was created using an EEA, LS, or RHS approach in 58.6%, 33.6%, and 7.7% of patients, respectively. 17.4% had an EGD (19.9% EEA, 13.9% LS, and 14.0% RHS). Incidence of MU was 7.3% (9.3% EEA, 4.8% LS, and 5.8% RHS). Rates of EGD and MU were significantly higher after EEA vs. LS GJA (p<0.05). The bleeding rate was 1.5%, [1.1% EEA, 2.1% LS, and 2.3% RHS (p=NS)]. MU within 90 days of RYGB occurred in 4.1%, 0.8%, and 4.7%, respectively (p<0.05 for EEA vs LS only). NSAID and cigarette use were identified in 29.3%, 38.9%, and 60% and 17.2%, 22.2%, and 20%, respectively, for the EEA, LS, and RHS GJA (p=NS). CONCLUSION: The method of GJA has an impact on rate of MU formation. A GJA fashioned with a 25-mm EEA stapler tends to have higher rates of EGD and MU.

S146-Jejunojejunal intussusception after roux-En-Y gastric bypass: a case series of 34 patients.

INTRODUCTION: Jejunojejunal intussusception (JI) is a serious but rare complication that may occur following Roux-en-Y gastric bypass (RYGB) surgery. Causes of JI and best management strategy are not clearly defined. METHODS: Electronic health records were queried for ICD 9/10 codes for intussusception after RYGB surgery (2009-2019), and charts retrospectively reviewed. Patient demographics, operative technique, presentation, radiology, and JI management were analyzed. RESULTS: Of the 2,327 RYGB patients identified at our institute, 34 (1.5%) were treated for JI. The mean age was 45.0 ± 8.6 years, mean BMI (RYGB surgery) was 43.1 ± 8.2 kg/m2, mean BMI at JI was 28.3 ± 5.8 kg/m2, and 30/34 were female, The mean time between RYGB and JI was 5.5 ± 4.3 years (range 1-17 years). Of the JI patients identified, 9 had operative notes that did not include jejunojejunostomy linear stapler length (JJ-LSL). Of the remaining 25 JI patients, 9 had a 60-mm JJ-LSL and 16 had a 120-mm JJ-LSL. Rate of intussusception was higher in the 120-mm versus 60-mm JJ-LSL group (p < 0.05). Acute abdominal pain was present in all JI patients and 32/34 had radiologic findings (CT scan) that corroborated for JI. The majority of JI patients were managed operatively (26/34) with 22/26 using laparoscopy (2/22 were converted to open). Intraoperative findings included intussusception (15/26), and 9/26 had other pathologies (internal hernia (2/26), cholecystitis (4/26), marginal ulcer (3/26)). Operative management of JI was either reduction and enteropexy (7/15), reduction only (5/15), or JJ revision (3/15). Recurrence of JI occurred in 7/23 patients, of who 4/7 were managed operatively. CONCLUSIONS: In our experience, JI appears to be a relatively rare complication after RYGB surgery. However, for patients developing JI, the majority had a JJ length ≥ 120 mm, and most patients required operative management which was associated with a higher rate of conversion to open and risk of JI recurrence. Reduction only technique had the highest risk of JI recurrence and therefore is not recommended.

Outcomes of adolescents compared with young adults after bariatric surgery: an analysis of 227,671 patients using the MBSAQIP data registry.

BACKGROUND: Obesity in the United States is increasingly prevalent in adolescents. Metabolic and bariatric surgery is offered at select sites to adolescents (<18 yr). Controversy exists regarding the safety of performing metabolic and bariatric surgery in adolescents. OBJECTIVES: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program registry was employed to compare outcomes of adolescents with adults (18-40 yr) undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). SETTING: Academic Teaching Institution. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files were reviewed for patients undergoing SG or RYGB (2015-2018). Patients were stratified by age and outcomes for adolescents versus adults compared. A bivariate analysis was performed on propensity-matched data. RESULTS: After exclusion criteria were applied, 227,671 patients <40 years remained, of whom 1005 were adolescents. For those undergoing RYGB (13.8% adolescents, 25.3% adults), demographic characteristics were similar. Adolescent SG patients were more likely to be male and Hispanic, but less likely to be smokers or have preoperative co-morbidities. There were no differences in infection rates, mortality, major complications, reoperation, readmission, or other interventions for RYGB and SG groups. For both adult SG and adolescent SG, patients' operative times were less than adult and adolescent RYGB, respectively. However, operative times were shorter for adolescent RYGB versus adult RYGB patients, yet longer for adolescent SG patients versus adult SG patients. CONCLUSIONS: Metabolic and bariatric surgery is as safe for adolescents undergoing an SG or RYGB as adults. Currently, SG is more commonly performed in adolescents than RYGB, and adolescent SG patients have similar outcomes and shorter operating room times compared with adolescent RYGB patients.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry.

BACKGROUND: The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients. METHODS: The MBSAQIP database was reviewed for RYGB and SG patients (2015-2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes. RESULTS: After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak. CONCLUSION: African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Anterior knee schwannoma.

Peripheral nerve tumors are relatively uncommon with schwannomas being the most common type. Schwannomas are usually benign encapsulated tumors composed of neoplastic Schwann cells that generally do not transform to malignancy. Many are discovered incidentally as solitary tumors. The cause is unknown. Most occur spontaneously, while some develop in association with genetic disorders such as neurofibromatosis type 2 or schwannomatosis. Schwannomas can occur anywhere in the body. They affect all ages, with peaking incidence between ages 20 and 50 years, without predilection to sex or race. Many are asymptomatic; however, presenting signs and symptoms, such as paresthesia and pain, are due to mass effect and direct nerve invasion. Diagnosing includes combinations of thorough physical examination, imaging modalities such as magnetic resonance imaging and surgical biopsy. Treatment depends on factors such as location of the tumor and severity of symptoms. Asymptomatic patients are treated conservatively while symptomatic patients undergo surgical resection with favorable prognosis.

Single Anastomosis Duodeno-Ileal Switch (SADIS): A Systematic Review of Efficacy and Safety.

BACKGROUND: Owing to the possibility of weight regain after the long-term follow-up of gastric bypass patients and because of the high morbidity of biliopancreatic diversion with duodenal switch, single-anastomosis duodeno-ileal switch (SADIS) has emerged as a rescue procedure in bariatric surgery. OBJECTIVE: The purpose of this review is to summarize the literature data on SADIS. SETTING: University Hospital, NY. METHODS: A comprehensive literature review was performed through October 2016 to identify English studies on SADIS performed in human subjects. Outcomes of interest were technical considerations, postoperative complications, weight loss outcome, comorbidity resolution rate, and nutritional deficiency after SADIS. RESULTS: A total of 12 studies including 581 SADIS patients (217 males and 364 females) were included. SADIS was a primary procedure in 508 patients (87.4%) and a conversion procedure in 73 patients (12.6%). The length of common limb was 300 cm in 54.2%, 250 cm in 23%, and 200 cm in 13.4% of patients. Anastomosis technique was a linear stapler in 26.7% and a hand sewn suture technique in 73.3% of patients. Diarrhea was the most common complication (1.2%). The average %EWL was 30% at 3 months, 55% at 6 months, 70% at 1 year, and 85% at 2 years. Co-morbidity resolution rate was 74.1% for type 2 diabetes mellitus, 96.3% for hypertension, 68.3% for dyslipidemia, 63.3% for obstructive sleep apnea, and 87.5% for GERD. Overall, vitamin A, selenium, and iron deficiency were the most common nutritional deficiencies with the possibility of the protein malnutrition in up to 34% of the patients when measured. CONCLUSION: As a modified bariatric procedure, SADIS has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients. When measured, there was a high prevalence of macro-nutrient deficiencies following SADIS. There is a high technical variability, and long-term data are required before any meaningful conclusion can be made.

Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review.

BACKGROUND: Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. OBJECTIVES: This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. METHODS: PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. RESULTS: A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). CONCLUSION: OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.