Case report: Concurrent intussusception and bleeding marginal ulcer in a patient with gastric bypass.

INTRODUCTION: The source of abdominal pain in patients with a history of gastric bypass can be difficult to determine. Synchronous disease processes may ultimately be the cause of their symptoms. Among the etiologies for hematemesis and obstruction in this population are the diagnoses of marginal ulcer and internal hernia. Given the potential complications of bariatric surgery, it is important to maintain a broad differential diagnosis during the workup of these patients. PRESENTATION: A female with history of laparoscopic Roux-en-Y gastric bypass (RYGB) presented with abdominal pain and hematemesis. Intraoperative findings revealed intussusception of the jejunojejunostomy resulting in obstruction and ischemic bowel. Additionally, a perforated marginal ulcer of the Roux-limb was found to be present. This patient underwent esophagogastroduodenoscopy, bowel resection, jejunojejunostomy revision, and Graham patch repair. DISCUSSION: This case highlights a patient with history of RYGB presenting with obstruction and gastrointestinal bleeding. Although initially diagnosed with internal hernia and Mallory-Weiss hematemesis, surgical exploration revealed concurrent intussusception and marginal ulceration. While intussusception is a rare complication of bariatric surgery, it can occur secondary to mesenteric thinning and motility dysfunction from significant weight loss. It is imperative to maintain a broad differential diagnosis for the causes of obstruction and GI bleeding that include adhesive disease, abdominal wall hernia, internal hernia, intussusception, and marginal ulcers. CONCLUSION: Findings of obstruction or GI bleeding after bariatric surgery may represent a surgical emergency. While these symptoms may be attributed to a single diagnosis, clinicians must consider the presence of synchronous pathologies during the workup of patients.

A Medium-Term Comparison of Quality of Life and Pain After Robotic or Laparoscopic Cholecystectomy.

INTRODUCTION: We sought to compare medium-term outcomes between robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC) using validated quality of life (QoL) and pain assessments. MATERIALS AND METHODS: Patients who underwent RC or LC between 2012 and 2017 at a single academic institution were examined. Cases converted to open were excluded. Patients were contacted by telephone in 2019 and completed two standardized surveys to rate their QoL and pain. RESULTS: Of those screened, 122 (35.8%) completed both surveys. Ninety three (76.2%) underwent RC and 29 (23.8%) underwent LC. The groups (RC versus LC) were similar based on mean age (47.9 versus 45.5 y, P = 0.48), gender (66.7% versus 72.4% female, P = 0.56), race (86.0% White/5.4% Black versus 72.4% White/13.8% Black, P = 0.2), insurance status (98.9% versus 100.0% insured, P = 0.58), median body mass index (31.8 versus 31.3, P = 0.43), and median Charlson Comorbidity Index (1 versus 0, P = 0.14). Fewer RC patients had a history of steroid use compared to LC (16.1% versus 34.5%, P = 0.03). No overall significant difference in QoL was demonstrated. LC group had higher severity of "tiring-exhausting pain" (P = 0.04), "electric-shock pain" (P = 0.003), and "shooting pain" (P = 0.05). The "overall intensity" of pain in the "gallbladder region" between the groups was similar at the time of follow-up (P = 0.31). CONCLUSIONS: QoL over 2-7 y following time of surgery is comparable for robotic-assisted versus conventional laparoscopic cholecystectomies. The laparoscopic approach may be associated with a higher severity of subset categories of pain, but overall pain between the two approaches is comparable.

Case report: Splenic artery pseudoaneurysm mimicking a bleeding marginal ulcer in a patient with gastric bypass.

INTRODUCTION: Upper gastrointestinal (GI) bleeding in patients with roux-en-Y gastric bypass can be difficult to localize. Marginal ulcers are the most common cause, but a broad differential should be maintained in cases of severe bleeding, especially since the stomach and duodenum are not easily accessible by regular upper endoscopy. PRESENTATION OF CASE: A 38-year-old female with Roux-en-Y gastric bypass presented with abdominal pain and hematochezia. Due to history of smoking and heavy use of ibuprofen, she was initially thought to have a bleeding marginal ulceration. Further investigation with computed tomographic (CT) angiography revealed a splenic artery pseudoaneurysm that had ruptured into a pancreatic pseudocyst, the gastric remnant and the peritoneum. The patient underwent successful treatment with trans-arterial embolization. DISCUSSION: Splenic artery pseudoanerysms are rare but potentially lethal if unrecognized, particularly in patients with altered foregut anatomy. Their most likely origin is a nearby pancreatic pseudocyst, which erodes into the splenic artery by direct pressure and enzymatic digestion. Bleeding inside the pseudocyst is the most feared complication, resulting in massive intraperitoneal, extraperitoneal or endoluminal hemorrhage. Surgery is particularly challenging due to intense peripancreatic inflammation. Trans-Anterial embolization is the preferred treatment modality. CONCLUSION: Marginal ulcers continue to be the most common cause of GI bleeding in patients with Roux-en-Y anatomy, although high index of suspicion for alternative diagnosis should be maintained in cases of massive hemorrhage.

Effect of Bacillius Coagulans and Galactomannans on Obese Patients Undergoing Sleeve Gastrectomy, A Randomized-Controlled Clinical Trial.

BACKGROUND: The purpose of this study was to examine the effect of probiotics and prebiotics (LactoWise®) on weight loss, blood pressure, and clinical lab values in morbidly obese patients undergoing laparoscopic sleeve gastrectomy (LSG). MATERIALS METHODS: Sixty patients undergoing LSG were recruited to participate in the study and randomized into either a LactoWise® or placebo group. The LactoWise® group (LWG) received 4.5 billion live cells of bacillus coagulans and galactomannans (300 mg); the placebo group received 600 mg of calcium citrate yielding 126 mg of elemental calcium. Both groups took their assigned capsule daily for 3-months post-surgery. Standard clinical lab values were measured pre-surgery and at 3-months post-surgery. Weight and blood pressures were measured at baseline, 2 weeks, 6 weeks, and 3 months post-surgery. RESULTS: A total of 35 patients with a mean age of 47.7 ± 12.4 years and a mean body mass index (BMI) of 46.6 ± 8.2 kg/m2 completed the study. There was a significant difference in BMI at baseline between the two study groups (43.0 ± 7.0 vs. 49.2 ± 8.3, P = .02). Weight loss was greater in the LWG compared to placebo at 6 weeks but showed no significant difference at 3 months post-op. In addition, there was a significant drop in triglycerides (TG) (P = .02) over time in the LWG (P = .01). The LWG had a significant decrease in AST and LDL compared to the placebo group (P = .03). CONCLUSION: Bariatric surgery (BS) produces positively impacting metabolic results in morbidly obese patients. Our study shows that in the case of triglycerides, LDL, weight loss and AST, administering of a probiotic/prebiotic blend may play a role in improving clinical outcomes of morbidly obese patients undergoing LSG.

Obesity and the role of bariatric surgery in the surgical management of osteoarthritis of the hip and knee: a review of the literature.

Obesity accelerates the development of osteoarthritis of the knee and hip by exerting deleterious effects on joints through both biomechanical and also systemic inflammatory changes. The objective of this review was to evaluate the impact of obesity on lower limb biomechanics and total joint arthroplasty outcomes, as well as weight changes after joint arthroplasty and the role of bariatric surgery among patients requiring joint arthroplasty. The currently published data indicate that weight loss increases swing time, stride length, gait speed, and lower extremity range of motion. Total joint arthroplasty improves pain and joint function, but does not induce significant weight loss in the majority of patients. Bariatric surgery improves gait biomechanics, and in the severely obese patient with osteoarthritis improves pain and joint function. The evidence for supporting bariatric surgery before total joint arthroplasty is limited to retrospective reports with conflicting results. Fundamental clinical questions remain regarding the optimal management of morbid obesity and lower extremity arthritis, which should be the focus of future collaborations across disciplines providing care to patients with both conditions.

The prevalence of overweight and obesity in a breast clinic population: consideration for weight loss as a therapeutic intervention.

BACKGROUND: Obesity is an important risk factor for breast cancer and weight loss may be associated with a decreased risk for breast cancer and its recurrence. We evaluated the prevalence of overweight, obesity, and obesity-related co-morbidities in a breast health clinic population to determine the potential need for weight loss intervention. METHODS: A retrospective review was conducted of sequential patients seen at a breast health clinic from July 1 to December 31, 2011. Body mass index (BMI), reason for visit (breast cancer diagnosis, high risk for breast cancer, or benign condition), and presence of obesity-related co-morbidities were recorded. RESULTS: The 302 patients who met inclusion criteria had a median age of 52 years (10-91) and median BMI of 26 kg/m(2) (15.4-56.5). Overall, 36.8% of patients had a BMI between 18.5-24.9 kg/m(2); 32.1%, 25-29.9 kg/m(2); 14.2%, 30-34.9 kg/m(2); 8.3%, 35-39.9 kg/m(2); and 4.3%, ≥ 40 kg/m(2). Overweight or obesity (BMI ≥ 25 kg/m(2)) occurred in 64.2% of breast cancer, 65.0% of high-risk, and 57.1% of benign patients (P value not significant). Criteria for bariatric surgery (BMI 35-39.9 kg/m(2) with ≥ 1 obesity-related co-morbidity or BMI ≥ 40 kg/m(2)) were met in 8.2% of breast cancer, 16.7% of high-risk, and 11.5% of benign patients (P value not significant). CONCLUSIONS: Regardless of diagnosis, a significant proportion of patients visiting the breast health clinic meet criteria for weight loss intervention, including bariatric surgery. Weight management represents an underutilized therapeutic modality that could potentially decrease the risk of breast cancer and its recurrence, and improve overall prognosis.

Early experience with intraluminal reinforcement of stapled gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The use of extraluminal staple-line buttressing material during laparoscopic Roux-en-y gastric bypass has shown the potential to reduce staple-line leak and bleeding. We herein present our early experience with intraluminal reinforcement of linear-cutting stapled gastrojejunal anastomosis with the use of bioabsorbable glycolide copolymer staple-line reinforcement. METHODS: Laparoscopic Roux-en-Y gastric bypass was performed in 80 consecutive non-randomized morbidly obese patients. Gastrojejunal anastomosis was performed using a linear-cutting stapler without staple-line reinforcement in 40 patients (group A), while in the other 40 patients (group B), gastrojejunostomy was performed using a linear cutting stapler with intraluminal reinforcement material (bioabsorbable glycolide copolymer). Demographic data were collected. The rate of gastrojejunal anastomotic leak, bleeding, and stricture was determined. RESULTS: There was a statistically significant reduction in bleeding complications between the two groups (15% bleeding in group A vs. no bleeding in group B, P value=0.0255). Stricture rate was higher in-group A (10% group A vs. 2.5% in group B); however, the difference was not statistically significant (P value=0.2007). None of our patients developed a gastrojejunal leak. CONCLUSION: Intraluminal reinforcement of gastrojejunal anastomosis during laparoscopic gastric bypass is safe and feasible. The use of intraluminal bioabsorbable glycolide copolymer staple-line reinforcement significantly reduces the incidence of gastrojejunal bleeding.