Erosions after laparoscopic adjustable gastric banding: diagnosis and management.

OBJECTIVE: To define the changing prevalence of erosion after Laparoscopic Adjustable Gastric Banding (LAGB), describing the range of clinical presentations, the approaches to treatment and the outcomes from these approaches over a 15-year study period. BACKGROUND: A recent systematic review of the literature of erosion after LAGB identified 25 relevant studies and reported a total of 231 erosions in 15,775 patients giving an overall incidence of 1.46%. The review highlighted a broad variation of incidence from 0.2% to 33%. The review was unable to identify either common presentations or an optimal pattern of management. METHODS: Patients who underwent a primary LAGB operation between September 1994 and January 2010 by 2 surgeons (P.O.B. and W.B.) were identified in a prospectively maintained database. Those patients who had an erosion of their LAGB were identified. Presentation, operative details, demographics, body mass index, weight history, and perioperative problems were analyzed. RESULTS: In total, 2986 patients were identified. All bands placed were Lap-Bands (Allergan, CA). Hundred erosions were experienced by 85 patients (2.85%) at a median time of 33 months from initial surgery to the erosion (range: 11-170 months). The rate of erosion was highest when the band was placed by the perigastric approach at 6.77%. Since the adoption of the pars flaccida approach, the rate of erosion has dropped to 1.07%. The majority of patients who had experienced an erosion (71 patients; 83.5%) experienced only 1 erosion, 13 patients (15.3%) had 2 erosions, and 1 patient had 3 erosions. The most common presentation was loss of satiety. The band has been successfully replaced in 56 patients. It has been explanted in 27 patients and 2 patients were converted to other bariatric procedures. The weight loss in patients who had a LAGB reinserted after erosion was not significantly different to the background cohort. CONCLUSIONS: Erosion of LAGB is uncommon and its clinical course is benign. It is best treated with a staged surgical approach; initially, with removal and repair followed later by replacement. With this approach, weight loss is maintained and reerosion is uncommon.

Primary laparoscopic sleeve gastrectomy versus gastric bypass: a propensity-matched comparison of 30-day outcomes.

BACKGROUND: Bariatric surgery is the most effective treatment for obesity. There is uncertainty regarding rates of adverse outcomes between the most common methods: laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: To compare rates of readmission, reoperation, intervention, unplanned intensive care unit (ICU) admission, all-cause and procedure-related mortality, and postoperative complications at 30 days between LRYGB and LSG. SETTING: Retrospective, observational, multicenter registry. METHODS: We identified 611,619 patients from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry between January 1, 2015, and December 31, 2018 (447,326 [73.1%] LSG; 164,293 [26.9%] LRYGB). RESULTS: Adverse events were more common after LRYGB (readmission: 3% with LSG versus 5.9% with LRYGB [P < .001; odds ratio {OR}, LSG/LRYGB = .489]; intervention: .9% with LSG versus 2.4% with LRYGB [P < .001; OR, LSG/LRYGB = .357]; reoperation: .8% with LSG versus 2.3% with LRYGB [P < .001; OR, LSG/LRYGB = .363]; unplanned ICU admission: .52% with LSG versus 1.1% with LRYGB [P < .001; OR, LSG/LRYGB = .454]; all-cause mortality: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .489]; procedure-related mortality: .04% with LSG versus .08% with LRYGB [P < .001; OR, LSG/LRYGB = .446]; Clavien-Dindo I: .20% with LSG versus .63% with LRYGB [P < .001; OR, LSG/LRYGB = .317]; Clavien-Dindo II: .70% with LSG versus 1.3% with LRYGB [P < .001; OR, LSG/LRYGB = .527]; Clavien-Dindo III: 3.3% with LSG versus 6.6% with LRYGB [P < .001; OR, LSG/LRYGB = .481]; Clavien-Dindo IV: .36% with LSG versus .76% with LRYGB [P < .001; OR, LSG/LRYGB = .466]; and Clavien-Dindo V: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .488]). Surgery type was among the strongest independent predictors of adverse events, and LRYGB conferred higher adjusted odds of all adverse outcomes (all-cause mortality: OR, LRYGB/LSG = 1.791 [P < .001]; procedure-related mortality: OR, LRYGB/LSG = 1.979 [P < .001]; readmission: OR, LRYGB/LSG = 1.921 [P < .001]; unplanned ICU admission: OR, LRYGB/LSG = 1.870 [P < .001]; intervention: OR, LRYGB/LSG = 2.662 [P < .001]; reoperation: OR, LRYGB/LSG = 2.646 [P < .001]; and Clavien-Dindo grade: OR, LRYGB/LSG = 2.007 [P < .001]). CONCLUSION: The rates of 30-day adverse outcomes are lower after LSG compared with after LRYGB. LRYGB independently conferred increased odds of adverse outcomes compared with LSG, and surgery type was among the strongest predictors of adverse outcomes.

Selective nonoperative management of leaks after gastric bypass: lessons learned from 2675 consecutive patients.

OBJECTIVE: To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management. SUMMARY OF BACKGROUND DATA: There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death. METHODS: We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management. RESULTS: Leaks occurred in 46 patients (41 women) with mean (+/-SD) age of 46.9 +/- 8.7 years, weight and body mass index (BMI) of 307.8 +/- 56.9 lb and 51.2 +/- 9.5 kg/m, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths. CONCLUSIONS: Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.

Laparoscopic repair of umbilical hernias in conjunction with other laparoscopic procedures.

BACKGROUND: This study evaluates the feasibility of laparoscopic transfascial suture repair of umbilical hernias when combined with another laparoscopic procedure that potentially contaminates the peritoneal cavity. METHOD: From August 1997 to November 2001, 32 patients underwent laparoscopic umbilical suture repair in association with another laparoscopic procedure. The repair was performed with the Carter-Thomason suture passer. RESULTS: Of the 32, 26 patients with more than 1-year follow-up were included in the study. The mean diameter of the umbilical hernia defect was 1.67 cm (range, 0.5 to 3). At a mean follow-up of 34 months (range, 12 to 60), there were only 2 recurrences (7.7%) both of which happened in patients with hernia defects larger than 2 cm in diameter. Apart from 2 wound infections, no other complications occurred. CONCLUSION: Laparoscopic suture repair of umbilical hernias with the suture passer method is effective and durable even when combined with other laparoscopic procedures that potentially contaminate the peritoneal cavity with bile or enteric contents.

Can low-molecular-weight heparins improve outcome in patients with cancer?

Patients with cancer who experience a thrombotic episode have a greater mortality rate than those without thromboembolic complications. VTE appears to be a more aggressive disease in patients with cancer, who often have a greater thrombus burden than cancer-free patients. An increased risk of VTE associated with certain tumour types, such as ovarian cancer, may be linked to overexpression of coagulation proteases. Retrospective trial data suggest that LMWHs prolong survival in some cancers. LMWHs are effective both in the prevention and treatment of thromboembolic disease in patients with cancer and this may be their most important effect, contributing to an improved outcome. They may also act by inhibiting coagulation proteases, which affect tumour biology or by a direct effect on malignant cells. A prospective trial to investigate the effect of long-term treatment with the LMWH dalteparin on survival of patients with advanced cancer is currently being evaluated.

T-tube jejunostomy feeding after pancreatic surgery: a safe adjunct.

OBJECTIVE: Patients with pancreatic disease are often malnourished because of biliary and gastric outlet obstruction or the catabolic response to sepsis or cancer. In this study, we reviewed our experience of providing enteral nutrition through a T-tube jejunostomy in these patients. METHODS: The records of a consecutive series of 36 patients who had undergone pancreatic operations during the last 4 years were reviewed. Data were collected on preoperative nutritional status and postoperative feeding. RESULTS: All patients had partially hydrolysed feeds administered through a T-tube jejunostomy, placed during pylorus-preserving proximal pancreatoduodenectomy (21 patients), Whipple's procedure (4), debridement of pancreatic necrosis (3), palliative bypass (2), distal pancreatectomy (2), cyst-jejunostomy (3) or accessory sphincteroplasty (1). Tube feeding was employed for a mean of 18 days. There were no related deaths. Eight patients had complications directly attributable to the tube, including blockage (4), dislodgement (2), pericatheter leakage (2) and peritonitis (1). Twenty patients had complications related to feeds that included transient diarrhoea (13), abdominal distension (8), nausea or vomiting (6) and pain (6). Consequently, nitrogen and energy needs were completely fulfilled in only 19 patients. CONCLUSION: Despite many minor shortcomings, jejunostomy tube feeding appears to be a safe adjunct to pancreatic surgery.

Supergastrinoma: simultaneous peptic ulceration of esophagus, stomach, and small intestine.

Synchronous involvement of the esophagus, stomach, and small intestine by peptic ulceration has not been previously described in the Zollinger-Ellison syndrome. Two patients presented with abdominal pain, diarrhea, weight loss, and dysphagia while on acid suppressants. Fasting hypergastrinemia was confirmed. Endoscopy revealed peptic stricture of the esophagus with ulcerations in the stomach, duodenum, and jejunum. Imaging showed a mass in the head of pancreas. The first patient underwent distal esophagectomy, total gastrectomy, and resection of the head of pancreas for a pancreatic primary. Resection of the third and fourth parts of the duodenum and proximal jejunum was undertaken in the second patient with a duodenal primary. Malignant gastrinoma was confirmed histologically. "Supergastrinoma" describes a tumor causing synchronous peptic ulceration and/or stricture extending from the esophagus to the jejunum. Operative management entails customized resection of the areas irretrievably damaged by the ulceration together with the tumor.

American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer.

PURPOSE: To develop guideline recommendations for the use of anticoagulation in the prevention and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS: A comprehensive systematic review of the medical literature on the prevention and treatment of VTE in cancer patients was conducted and reviewed by a panel of content and methodology experts. Following discussion of the results, the panel drafted recommendations for the use of anticoagulation in patients with malignant disease. RESULTS: The results of randomized controlled trials of primary and secondary VTE medical prophylaxis, surgical prophylaxis, VTE treatment, and the impact of anticoagulation on survival of patients with cancer were reviewed. Recommendations were developed on the prevention of VTE in hospitalized, ambulatory, and surgical cancer patients as well as patients with established VTE, and for use of anticoagulants in cancer patients without VTE to improve survival. CONCLUSION: Recommendations of the American Society of Clinical Oncology VTE Guideline Panel include (1) all hospitalized cancer patients should be considered for VTE prophylaxis with anticoagulants in the absence of bleeding or other contraindications; (2) routine prophylaxis of ambulatory cancer patients with anticoagulation is not recommended, with the exception of patients receiving thalidomide or lenalidomide; (3) patients undergoing major surgery for malignant disease should be considered for pharmacologic thromboprophylaxis; (4) low molecular weight heparin represents the preferred agent for both the initial and continuing treatment of cancer patients with established VTE; and (5) the impact of anticoagulants on cancer patient survival requires additional study and cannot be recommended at present.