Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study.

BACKGROUND: When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE: We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN: We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING: Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS: A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION: Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES: The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS: There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = -2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted P < 0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (P = 0.034). CONCLUSION: Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION: NCT02452060. : This article is accompanied by the following Invited Commentaries:Mion G. Ketamine stakes in 2018. Right doses, good choices. Eur J Anaesthesiol 2019; 36:1-3.Robu B, Lavand'homme, P. Targeting the affective component of pain with ketamine. A tool to improve the postoperative experience? Eur J Anaesthesiol 2019; 36:4-5.

Previous weight loss as a predictor of weight loss outcomes after laparoscopic adjustable gastric banding.

INTRODUCTION: Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary LAGB patients. METHODS: A retrospective cohort study was designed from a prospectively collected database at a single institution. Inclusion criteria consisted of age ≥18 years, initial body mass index (BMI) ≥35 kg/m(2), intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery were excluded. Outcomes included mean % excess weight loss (EWL), percent that achieved weight loss success (%EWL ≥ 40), and percent with suboptimal weight loss (%EWL < 20) at 2 years post-LAGB. RESULTS: In the study, 462 primary LAGB patients were included. Mean previous weight loss was 29.7 lb (SD 27.6, range 0-175). These patients were divided into four previous weight loss groups (0, 1-20, 21-50, >50 lb) for analysis. In adjusted multivariate analyses, patients with >50 lb of maximum previous weight loss had a significantly higher mean %EWL, (p < 0.0001) and %BMIL (p < 0.0001), were more likely to reach weight loss success (≥40 % EWL, p = 0.047), and were less likely to experience suboptimal weight loss (<20 % EWL, p = 0.027) at 2 years postoperatively. CONCLUSION: Previous weight loss appears to be a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study.

BACKGROUND: Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS: A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS: Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS: Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy.

BACKGROUND: Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. METHODS: A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. RESULTS: A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. CONCLUSION: Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis.

BACKGROUND: The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice. METHODS: A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery. RESULTS: There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20% (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group. CONCLUSIONS: Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Sustained weight loss after gastric banding revision for pouch-related problems.

OBJECTIVE: To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months. BACKGROUND: There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose. METHODS: A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation. RESULTS: Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m, and %EWL was 47.50 ± 22.91% twenty-four months postrevision. CONCLUSIONS: Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.

Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes.

BACKGROUND: Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups. METHODS: We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality. RESULTS: A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths. CONCLUSIONS: SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

Location and number of sutures placed for hiatal hernia repair during laparoscopic adjustable gastric banding: does it matter?

BACKGROUND: It has been demonstrated that hiatal hernia repair (HHR) during laparoscopic adjustable gastric banding (LAGB) decreases the rate of reoperation. However, the technical aspects (location and number of sutures) are not standardized. It is unknown whether such technical details are associated with differing rates of reoperation for band-related problems. METHODS: A retrospective analysis was performed from a single institution, including 2,301 patients undergoing LAGB with HHR from July 1, 2007 to December 31, 2011. Independent variables were number and location of sutures. Data collected included demographics, operating room (OR) time, length of stay (LOS), follow-up time, postoperative BMI/%EWL, and rates of readmission/reoperation. Statistical analyses included ANOVA and Chi squared tests. Kaplan-Meier, log-rank, and Cox regression tests were used for follow-up data and reoperation rates, in order to account for differential length of follow-up and confounding variables. RESULTS: There was no difference in length of follow-up among all groups. The majority of patients had one suture (range 1-6; 55 %). Patients with fewer sutures had shorter OR time (1 suture 45 min vs. 4+ sutures 56 min, p < 0.0001). LOS, 30-day readmission, band-related reoperation, and postop BMI/%EWL were not statistically significant. Anterior suture placement (vs. posterior vs. both) was most common (61 %). OR time was shorter in those with anterior suture (41 min vs. posterior 56 min vs. both 59 min, p < 0.0001). Patients with posterior suture had a longer LOS (84 % 1 day vs. anterior 74 % 1 day vs. both 74 % 1 day, p < 0.0001). There was no difference in 30-day readmission, band-related reoperation, and postoperative BMI/%EWL. CONCLUSIONS: Patients with fewer or anterior sutures have shorter OR times. However, 30-day readmission, band-related reoperation, and postoperative weight loss were unaffected by number or location of suture. The technical aspects of HHR did not appear to be associated with readmission or reoperation, and therefore a standardized approach may not be necessary.

One Anastomosis Gastric Bypass for Revisional Bariatric Surgery: Assessment of Short-Term Safety.

PURPOSE: With the continued increase in bariatric procedures being performed in the USA, a growing percentage are revisions for weight regain after sleeve gastrectomy (SG) and gastric banding (LAGB). Standard practice in the USA involves conversion to Roux-en-Y gastric bypass (RYGB). Internationally, one anastomosis gastric bypass (OAGB) has become a popular and effective alternative. Without the jejuno-jejunal anastomosis, OAGB has reduced potential related long-term complications. The purpose of this study is to compare the short-term safety of revision to OAGB versus RYGB. MATERIALS AND METHODS: Patients who underwent conversion to OAGB from LAGB or SG for weight regain from January 2019 to October 2021 were compared to BMI, sex, and age-matched patients who underwent conversion to RYGB. RESULTS: In our study, 82 patients were included, 41 in each cohort (41 OAGB vs. 41 RYGB). The majority in both groups underwent conversion from SG (71% vs. 78%). Operative time, estimated blood loss, and length of stay were comparable. There was no difference in 30-day complications (9.8% vs. 12.2%, p = .99) or reoperation (4.9% vs. 4.9%, p = .99). Mean weight loss at 1 month was also comparable (7.91 lbs vs 6.36 lbs). CONCLUSIONS: Patients undergoing conversion to OAGB for weight regain had similar operative times, post-operative complication rates, and 1-month weight loss compared to those who underwent RYGB. While more research is needed, this early data suggests that OAGB and RYGB provide comparable outcomes when used as conversion procedures for to failed weight loss. Therefore, OAGB may present a safe alternative to RYGB.

Does adding a lesser-curvature gastrogastric plication suture reduce the need for revision after laparoscopic adjustable gastric band placement?

BACKGROUND: The need for revision after laparoscopic adjustable gastric band (LAGB) surgery has been reduced over the past 10 years with the introduction of the pars flaccida technique, delicate band tightening, and concurrent hiatal hernia repairs. However, band revision still occurs for as many as 5% of patients. Placement of a lesser-curvature gastrogastric suture distal to the band is one newer technique suggested to lower band slippage. To evaluate the worth of this technique, the authors have investigated two groups of patients in their practice: one group with the plication stitch and one group without it. METHODS: This retrospective review examined data for 1,365 LAGB patients collected prospectively by an institutional review board-approved database between July 2007 and May 2010. One surgeon did not perform the plication stitch (n = 776) and one did (n = 589). The surgical techniques were very similar. The majority of the patients had crural repair at the primary operation. Band revision rates were assessed. RESULTS: For 1,365 patients, LAGB was performed safely. The mean follow-up period was 22 months. The two groups were similar. The no-stitch group consisted of 776 patients (496 women, 64%) with a mean age of 42 years, a mean weight of 278 lb, and a mean body mass index (BMI) of 44.6 kg/m(2). The stitch group consisted of 589 patients (426 woman, 72%) with a mean age of 40 years, a mean weight of 278 lb, and a mean BMI of 44.8 kg/m(2). The no-stitch group had an estimated weight loss (EWL) of 44% at 12 months and 50% EWL at 2 years. The stitch group had 37% EWL at 12 months and 45% EWL at 2 years. Both groups had very low revision rates. The no-stitch group had 4 revisions in 776 patients (0.26%), and the stitch group had 9 revisions in 589 patients (1.5%). CONCLUSION: Adding gastrogastric plication sutures offers no benefit of reducing the rate of revision after LAGB surgery.

Body Weight and Prandial Variation of Plasma Metabolites in Subjects Undergoing Gastric Band-Induced Weight Loss.

BACKGROUND: Bariatric procedures are safe and effective treatments for obesity, inducing rapid and sustained loss of excess body weight. Laparoscopic adjustable gastric banding (LAGB) is unique among bariatric interventions in that it is a reversible procedure in which normal gastrointestinal anatomy is maintained. Knowledge regarding how LAGB effects change at the metabolite level is limited. OBJECTIVES: To delineate the impact of LAGB on fasting and postprandial metabolite responses using targeted metabolomics. SETTING: Individuals undergoing LAGB at NYU Langone Medical Center were recruited for a prospective cohort study. METHODS: We prospectively analyzed serum samples from 18 subjects at baseline and 2 months after LAGB under fasting conditions and after a 1-hour mixed meal challenge. Plasma samples were analyzed on a reverse-phase liquid chromatography time-of-flight mass spectrometry metabolomics platform. The main outcome measure was their serum metabolite profile. RESULTS: We quantitatively detected over 4,000 metabolites and lipids. Metabolite levels were altered in response to surgical and prandial stimuli, and metabolites within the same biochemical class tended to behave similarly in response to either stimulus. Plasma levels of lipid species and ketone bodies were statistically decreased after surgery whereas amino acid levels were affected more by prandial status than surgical condition. CONCLUSIONS: Changes in lipid species and ketone bodies postoperatively suggest improvements in the rate and efficiency of fatty acid oxidation and glucose handling after LAGB. Further investigation is necessary to understand how these findings relate to surgical response, including long term weight maintenance, and obesity-related comorbidities such as dysglycemia and cardiovascular disease.

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease.

BACKGROUND: The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE: To examine the effects of LSG on GERD symptoms. METHODS: One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS: For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7 kg/m2 respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION: These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss. OBJECTIVE: To compare the weight loss results of these 2 surgeries. SETTING: University hospital, United States. METHODS: A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations. RESULTS: The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGB = 32.93, LSG = 38.34, P = .0004), percent excess BMI lost (RYGB = 57.8%, LSG = 29.3%, P < .0001), and percent weight loss (RYGB = 23.4%, LSG = 12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, P = .0022), longer operating room time (RYGB = 120.1 min versus LSG = 115.5 min, P < .0001), and longer length of stay (RYGB = 3.33 d versus LSG = 2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, P = .087). CONCLUSION: Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE: To investigate long-term results of salvage gastric banding. SETTING: University Hospital, New York, United States. METHODS: Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS: A total of 168 patients underwent statistical analysis with 86 patients meeting inclusion for RYGB failure. The mean body mass index before RYGB was 48.9 kg/m2. Before LAGB, patients had an average body mass index of 43.7 kg/m2, with 10.4% total weight loss and 21.4% excess weight loss after RYGB. At 5-year follow-up, patients (n = 20) had a mean body mass index of 33.6 kg/m2 with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION: The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.

Thirty-Day Readmission After Laparoscopic Sleeve Gastrectomy­a Predictable Event?

BACKGROUND: Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG). METHODS: We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission. RESULTS: Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI = [1.19, 5.40]), intraoperative drain placement (OR 3.11, CI = [1.58, 6.13]), postoperative complications (OR 8.21, CI = [2.33, 28.97]), and pain at discharge (OR 8.49, CI = [2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR 72.4, CI = [15.8, 330.5]). CONCLUSIONS: The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

Weight loss outcomes among patients referred after primary bariatric procedure.

BACKGROUND: Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere. METHODS: We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management. RESULTS: Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001). CONCLUSIONS: Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.

Improvement in nonalcoholic fatty liver disease and metabolic syndrome in adolescents undergoing bariatric surgery.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. It is linked to obesity and the metabolic syndrome (MS), predisposing to future cirrhosis. The objective of this study was to demonstrate the effects that weight loss achieved with laparoscopic adjustable gastric band (LAGB) has on the metabolic parameters and NAFLD scores of obese adolescents with evidence of fatty liver disease. METHODS: Adolescents undergoing LAGB were evaluated for NAFLD with evidence of fatty liver on preoperative sonogram, serum biochemistry, or both between 2005 and 2011. Primary endpoint was change in NAFLD scores after LAGB and secondary endpoint change in MS criteria. RESULTS: Fifty-six out of 155 adolescents had evidence of fatty liver disease at presentation. The group consisted of 17 (30%) male and 39 (70%) females, mean age 16.1 years (range 14-17.8 yr). Preoperative body mass index (BMI) was 48.8 kg/m(2) (±7) dropping to 37.9 kg/m(2) (±8.3) at 12 months and 36.8 kg/m(2) (±8.2) at 24 months. Fifteen (27%) patients met the criteria for MS. When comparing 1-year postsurgery to presurgery, the NAFLD score decreased by an average of .68 (SD = 1.03, P<.01). The 2-year NAFLD score decreased by a mean of .38 (SD = .99, P = .01). The reoperation rate for band/port related complications was 10.7% at 2 years with no mortality. MS rates improved from 27% to 2% at 2 years (P< .01). CONCLUSIONS: LAGB is a safe and effective operation for obese adolescents with NAFLD. There was significant improvement in NAFLD scores and resolution of MS.

Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass.

BACKGROUND: Marginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers. METHODS: Data from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed. RESULTS: Twelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU. CONCLUSION: Patients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.

Safety and efficacy of laparoscopic adjustable gastric banding in patients aged seventy and older.

BACKGROUND: Life expectancy is increasing, with more elderly people categorized as obese. The objective of this study was to assess the effects of laparoscopic adjustable gastric banding (LAGB) on patients aged ≥ 70 years. METHODS: This was a retrospective analysis of patients aged ≥ 70 years who underwent LAGB at our university hospital between 2003 and 2011. The data included age, weight, body mass index (BMI), and percentage excess weight loss (%EWL) obtained before and after gastric banding. Operative data, length of stay, postoperative complications, and resolution of co-morbid conditions were also analyzed. RESULTS: Fifty-five patients aged ≥ 70 years (mean 73 years) underwent gastric banding between 2003 and 2012. Mean preoperative weight and BMI were 123 kilograms and 45 kg/m(2), respectively. On average, each patient had 4 co-morbidities preoperatively, with hypertension (n = 49; 86%), dyslipidemia (n = 40; 70%), and sleep apnea (n = 31; 54%) being the most common. Mean operating room (OR) time was 49 minutes, with all patients discharged within 24 hours. There was 1 death at 4 years from myocardial infarction, no intensive care unit admissions, and no 30-day readmissions. Mean %EWL at 1, 2, 3, 4, and 5 years was 36 (± 12.7), 40 (± 16.4), 42 (± 19.2), 41 (± 17.1), 50 (± 14.9), and 48 (± 22.6), respectively. Follow-up rates ranged from 55/55 (100%) at 6 months to 7/9 (78%) of eligible patients at 5 years and 2/2 (100%) at 8 years. Complications included 1 band slip at year 5, 1 band removed for intolerance, and 1 port site hernia. The resolution of hypertension, dyslipidemia, sleep apnea, lower back pain, and non-insulin-dependent diabetes was 27%, 28%, 35%, 31%, and 35%, respectively. CONCLUSIONS: LAGB as a primary treatment for obesity in carefully selected patients aged ≥ 70 can be well tolerated and effective with moderate resolution of co-morbid conditions and few complications.

Single-incision laparoscopic adjustable gastric banding is effective and safe: 756 cases in an academic medical center.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is safe and effective. This less invasive option involving fewer incisions and umbilical approaches is coined as single-incision laparoscopic surgery (SILS). Over the last 3 years, we performed 46 % of our LAGBs as SILS with excellent results. METHODS: This is a retrospective review of 1,644 LAGBs performed between 2008 and 2010. A total of 756 were performed as SILS bands (46 %) and 888 as standard (non-SILS) (54 %). Data points compared include operative time, percent of excess weight loss at 1 and 2 years, complication, and re-operation rates. RESULTS: Groups were matched by age, initial BMI, and gender: 584 non-SILS and 710 SILS patients. The average operating time was 44.3 ± 19.6 min for SILS and 51.1 ± 19.4 min for non-SILS (p < 0.001). The 12-month percent excess weight loss (%EWL) for SILS was 45.0 ± 19.1; it was 40.7 ± 17.5 for non-SILS (p = 0.003). The 24 month %EWL for SILS was 54.4 ± 16.3; it was 46.4 ± 16.1 for non-SILS (p = 0.10). Complication rates were 5.6 % (40 of 710) for SILS and 4.5 % (26 of 584) for non-SILS (p = 0.34). The 30-day readmission/re-operation rates are 1 % (seven of 710) for SILS and 1.5 % (nine of 584) for non-SILS (p = 0.37). There was one death in the SILS group. CONCLUSIONS: We have been performing more SILS bands over time. Our operative times and weight loss figures show that it is an efficient and effective means of weight loss. Furthermore, the data also show that the SILS approach is safe and does not increase operative time. In conclusion, SILS laparoscopic adjustable gastric banding is a safe and effective means of attaining weight loss in selected patients.