Safety of Single Stage Revision Laparoscopic Sleeve Gastrectomy Compared to Laparoscopic Roux-Y Gastric Bypass after Failed Gastric Banding.

BACKGROUND: Reoperation, after failed gastric banding, is a controversial topic. A common approach is band removal with conversion to laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in a single-step procedure. OBJECTIVE: This study aimed to assess the safety of revisional surgery to LSG compared to LRYGB after failed laparoscopic adjustable gastric banding (LAGB) based on MBSAQIP Participant User File from 2015 to 2018. METHODS: Patients who underwent a one-stage conversion of LAGB to LSG (Conv-LSG) or LRYGB (Conv-LRYGB) were identified in the MBSAQIP PUF from 2015 to 2017. Conv-LRYGB cases were matched (1:1) with Conv-LSG patients using propensity scoring to control for potential confounding. The primary outcome was all-cause mortality. RESULTS: A total of 9974 patients (4987 matched pairs) were included in the study. Conv-LRYGB, as compared with conv-SG, was associated with a similar risk of mortality (0.02% vs. 0.06%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.03 to 3.20, p = 0.32). Conversion to LRYGB increased the risk for readmission (6.16% vs. 3.77%; RR, 1.63; 95%CI, 1.37 to 1.94, p < 0.01); reoperation (2.15% vs. 1.36%; RR, 1.57; 95%CI, 1.17 to 2.12, p = <0.01); leak (1.76% vs. 1.02%; RR, 1.57; 95%CI, 1.72 to 2.42, p < 0.01); and bleeding (1.66% vs. 1.00%; RR, 1.66; 95%CI, 1.7 to 2.34, p < 0.01). CONCLUSIONS: The study shows that single-stage LRYGB and LSG as revisional surgery after gastric banding, are safe in the 30-day observation with an acceptable complication rate and low mortality. However, conversion to LRYGB increased the risk of perioperative complications.

The effect of smoking on bariatric surgical 30-day outcomes: propensity-score-matched analysis of the MBSAQIP.

BACKGROUND: The exact impact of smoking within the last 12 months on the safety outcome of sleeve gastrectomy and Roux-Y gastric bypass is not well known. The study aimed to assess the effects of smoking on 30-day surgical outcomes. METHODS: Preoperative characteristics and outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program dataset 2015-2018 were selected for all patients who underwent primary sleeve gastrectomy or Roux-Y gastric bypass. 30-day postoperative outcomes were assessed. We used propensity score matching to control for potential confounding. RESULTS: In laparoscopic sleeve gastrectomy group, 29 165 pairs were included in the analysis. Smoking increased risk for inpatients readmission rate (3.67% vs. 3.10%; RR, 1.18; 95%CI 1.08-1.29, p < 0.001), intervention rate (1.03% vs. 0.84%; RR, 1.22; 95%CI 1.00-1.24, p = 0.020), reoperation rate (0.99% vs. 0.79%; RR, 1.25; 95%CI 1.05-1.48, p = 0.010), and leak rate (0.59% vs. 0.32%; RR, 1.83; 95%CI 1.43-2.37, p < 0.001). In laparoscopic Roux-Y gastric bypass cohort,11 895 pairs were included in the ultimate analysis. Smoking increased risk for inpatients readmission rate (7.54% vs. 5.88%; RR, 1.28; 95%CI 1.16-1.41, p < 0.001), intervention rate (3.53% vs. 2.30%; RR, 1.54; 95%CI 1.32-1.80, p < 001), reoperation rate (3.17% vs. 1.86%; RR, 1.70; 95%CI 1.45-2.00, p < 0.001), leak rate (1.05% vs. 0.59%; RR, 1.78; 95%CI 1.33-2.39, p < 0.001), bleed rate (2.03% vs. 1.45%; RR, 1.39; 95%CI 1.15-1.69, p < 0.001), and morbidity (4.20% vs. 3.38%; RR, 1.24; 95%CI 1.09-1.41, p = 0.001). CONCLUSION: Smoking cigarettes at any point within the 12 months before admission for surgery increased the risk for surgical short-term complications in bariatric patients. The effect was the most significant regarding leaks.

Safety of same-day discharge after laparoscopic sleeve gastrectomy: propensity score-matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Registry.

BACKGROUND: Information on the safety of outpatient sleeve gastrectomy is sparse. OBJECTIVE: This study aimed to assess the safety of sleeve gastrectomy as a day case surgery. SETTING: University health network, United States. METHODS: Patients who underwent primary sleeve gastrectomy were identified in the 2015-2017 MBSAQIP database. Day case surgery procedure was defined as having a hospital length of stay of 0 days. Day case surgery patients were matched with inpatient controls using propensity score matching. The primary outcome was 30-day mortality. RESULTS: A total of 271,658 sleeve gastrectomy patients met the inclusion criteria. Of these, only 7825 (2.88 %) were day case surgery procedures. There was no mortality in the group. Day case surgery, compared with inpatient sleeve gastrectomy, was associated with a similar risk of a leak (.56% versus .40%; relative risk [RR], 1.419; 95% CI, .896-2.245; P = .133), bleeding (.38% versus .31%; RR, 1.250; 95% CI, .731-2.138; P = .414), 30-day reoperation (.81% versus .56%; RR, 1.432; 95% CI, .975-2.104; P = .066), and 30-day morbidity (1.15% versus 1.01%; RR, 1.139; 95% CI, .842-1.541; P = .397). Outpatients' SG increased the risk for 30-day readmission (3.35% versus 2.79%; RR, 1.202; 95% CI, 1.009-1.432; P = .039). CONCLUSIONS: Sleeve gastrectomy in the outpatient setting as a day case surgery was associated with no mortality and no statistically significant risk of reoperation, leakage, or bleeding compared with patients admitted to inpatient units. The readmission rate was higher in the day case surgery group.

Safety of concurrent sleeve gastrectomy and hiatal hernia repair: a propensity score-matched analysis of the MBSAQIP registry.

BACKGROUND: Hiatal hernia repair is an essential step to reduce the incidence of gastroesophageal acid reflux disease in patients undergoing sleeve gastrectomy. The safety of addition, a hiatal hernia repair to sleeve gastrectomy, is a critical question. OBJECTIVES: Our study aimed to assess the safety of concurrent hiatal hernia repair and sleeve gastrectomy based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data. SETTING: University health network, United States. METHODS: This study was a registry-based analysis. Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 to 2017 were selected for all patients who underwent sleeve gastrectomy with hiatal hernia repair. Propensity score matching (1:1) was used to control for potential confounding. RESULTS: A total of 101,902 patients (50,951 patients matched pairs) were included in the study. The groups were closely matched as intended. Sleeve gastrectomy with hiatal hernia repair, compared with sleeve gastrectomy alone, was associated with similar risks of death (.02% versus .02%; relative risk [RR], 1.50; 95% confidence interval [CI], .61-3.67, P = .503), and higher risk of 30-day readmission (4.01% versus 2.96%; RR, 1.35; 95%CI, 1.27-1.45, P < .001), 30-day reoperation (1.10% versus .77%; RR, 1.42; 95% CI, 1.25-1.61, P < .001), 30-day intervention (1.24% versus .95%; RR, 1.31; 95%CI, 1.16-1.47, P < .001), and 30-day morbidity (1.85% versus 1.47%; RR, 1.25; 95%CI, 1.14-1.38, P < .001). CONCLUSIONS: Sleeve gastrectomy with hiatal hernia repair is relatively safe in the short term with no increase in the risk of mortality. However, this additional procedure slightly increases the risk of readmission, reoperation, and postoperative intervention, as well as morbidity.

Jejuno-gastric intussusception: A case report of unusual cause of food intolerance after roux-En-Y gastric bypass.

INTRODUCTION: Morbid obesity is increasing worldwide as a result, weight loss procedures such as Roux- En-Y gastric bypass (RYGB) are increasing as well. RYGB has multiple complications including intussusception, most of the cases are jejuno-jejunal. Only one case reported to be Jejuno-gastric intussusception (JGI) but through the remnant and not the gastro-jejunostomy anastomosis (GJ). CASE REPORT: A 50-year-old female presented to the emergency department complaining of diffuse abdominal pain, nausea, and vomiting. Her surgical history is significant for an RYGB 17 years ago. Nausea and food intolerance were the most prominent symptoms. CT scan of the abdomen and upper GI series were normal. Only Esophagogastroduodenoscopy (EGD) showed JGI through GJ, with friable mucosa and a small gastro-gastric fistula. Patient underwent successful reconstruction of GJ and had no symptoms afterwards. CONCLUSION: JGI is a rare of cause of abdominal pain, nausea and vomiting after RYGB. Early diagnosis is crucial, a thorough work up is needed to make diagnosis of JGI including EGD. Revision of GJ anastomosis is necessary to address this phenomenon.

Decreased opioid consumption and enhance recovery with the addition of IV Acetaminophen in colorectal patients: a prospective, multi-institutional, randomized, double-blinded, placebo-controlled study (DOCIVA study).

BACKGROUND: We hypothesized that administration of IV acetaminophen alone would reduce the opioid consumption in post-operative colorectal surgery and reduce the side effects of narcotics. METHODS: Patients were randomized to receive either IV acetaminophen or placebo in addition to opioid PCA. Primary endpoints evaluated were opioid consumption and pain visual analogue scale score (PVASS) during first 48 h post-operatively. Secondary endpoints evaluated were time of return of GI function (ROGIF), time to diet ordered (TTDO), length of hospital stay (LOHS), and occurrence of ileus. RESULTS: 105 patients were enrolled and 97 remained in the study after exclusion (control group n = 50; study group n = 47). Mean ± SEs of opioid consumption in the study group was 21.5 ± 1.8 mg of morphine equivalent (ME) and 35.0 ± 3.3 mg ME at 24 and 48 h, respectively, versus 36.4 ± 4.1 mg ME and 59.7 ± 6.7 mg ME in the control group (p = 0.002 and 0.002). PVASS levels were lower in the study group at all intervals at 3, 8, 24, and 48 h (p = 0.02, 0.006, < 0.01, and 0.02). ROGIF, TTDO, and LOHS were also found to be lower in the study group (p ≤ 0.01, < 0.01, and 0.002). The rate of ileus was reduced by using IV acetaminophen (22% vs 2.1%; p = 0.004). CONCLUSIONS: IV acetaminophen helps to reduce opioid consumption for patients undergoing colorectal surgery. Additionally, there appears to be a shortened length of hospital stay, better pain control, reduced time to return of bowel function, and lower rate of post-operative ileus in patients receiving IV acetaminophen.

"Candy cane syndrome:" an underappreciated cause of abdominal pain and nausea after Roux-en-Y gastric bypass surgery.

BACKGROUND: "Candy cane" syndrome (a blind afferent Roux limb at the gastrojejunostomy) has been implicated as a cause of abdominal pain, nausea, and emesis after Roux-n-Y gastric bypass (RYGB) but remains poorly described. OBJECTIVES: To report that "candy cane" syndrome is real and can be treated effectively with revisional bariatric surgery SETTING: All patients underwent "candy cane" resection at University Hospitals of Cleveland. METHODS: All patients who underwent resection of the "candy cane" between January 2011 and July 2015 were included. All had preoperative workup to identify "candy cane" syndrome. Demographic data; pre-, peri-, and postoperative symptoms; data regarding hospitalization; and postoperative weight loss were assessed through retrospective chart review. Data were analyzed using Student's t test and χ2 analysis where appropriate. RESULTS: Nineteen patients had resection of the "candy cane" (94% female, mean age 50±11 yr), within 3 to 11 years after initial RYGB. Primary presenting symptoms were epigastric abdominal pain (68%) and nausea/vomiting (32%), particularly with fibrous foods and meats. On upper gastrointestinal study and endoscopy, the afferent blind limb was the most direct outlet from the gastrojejunostomy. Only patients with these preoperative findings were deemed to have "candy cane" syndrome. Eighteen (94%) cases were completed laparoscopically. Length of the "candy cane" ranged from 3 to 22 cm. Median length of stay was 1 day. After resection, 18 (94%) patients had complete resolution of their symptoms (P<.001). Mean body mass index decreased from 33.9±6.1 kg/m2 preoperatively to 31.7±5.6 kg/m2 at 6 months (17.4% excess weight loss) and 30.5±6.9 kg/m2 at 1 year (25.7% excess weight loss). The average length of latest follow-up was 20.7 months. CONCLUSION: "Candy cane" syndrome is a real phenomenon that can be managed safely with excellent outcomes with resection of the blind afferent limb. A thorough diagnostic workup is paramount to proper identification of this syndrome. Surgeons should minimize the size of the blind afferent loop left at the time of initial RYGB.

Predictive Factors for the Migration of Endoscopic Self-Expanding Metal Stents Placed in the Foregut.

BACKGROUND: With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aimed to determine predictive factors for stent migration. METHODS: Consecutive procedures involving SEMS placed with and without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic, surgical history, rate of stent migration, and stent characteristic data were collected. Rates of stent migration were compared. RESULTS: We reviewed 214 consecutive procedures involving stents placed in the foregut. Median duration of stent placement was 4.0 ± 10.3 weeks. Forty-three (20%) stents migrated after placement. Of those, 27 (63%) required stent replacement. Eleven (5%) procedures utilized stent fixation and 203 (95%) did not. Fixation techniques included endoscopic clips (9%), endoscopic sutures (73%), and transnasal sutures (18%). Stent migration rate was not different between those with and those without fixation ( P = .2). Rate of migration was significantly higher in procedures involving fully covered stents ( P < .001). Migration occurred after esophagectomy and gastric bypass ( P < .001 and P < .05, respectively) and in patients with diabetes ( P < .01). CONCLUSIONS: A challenge with SEMS use is stent migration. Diabetes and using fully covered stents were associated with migration as were SEMS used to treat complications of esophagectomy and gastric bypass. Stent fixation was not associated with the prevention of stent migration. No pattern was found that favors an approach to reduce stent migration.

Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS).

INTRODUCTION: Anastomotic or staple-line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents have been gaining popularity. In this study, we aimed to determine the safety and effectiveness of self-expanding covered stents in management of leak after foregut surgery. METHODS: Consecutive patients who received a fully covered self-expandable metal stent (SEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were collected. Predictive factors for clinical success rate were assessed. RESULTS: A total of 20 consecutive patients underwent placement of fully covered SEMS for anastomotic leak, following esophagectomy (n = 5), esophageal diverticulectomy (n = 1), gastric sleeve (n = 4), gastric bypass (n = 3), partial gastrectomy (n = 4), and total gastrectomy (n = 3). All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0.4-14). Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2). Two (10 %) patients' treatment was complicated by aorto-esophageal fistula formation resulting in one death. Demographic factors, comorbidities, and type of surgery were not predictive of clinical success rate or time to resolution. CONCLUSION: SEMS are effective tools for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Caution is warranted due to the risk of fatal complications such as aorto-esophageal fistula formation. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate. Larger studies are needed to determine factors predictive of clinical success.