Long-term outcomes following laparoscopic Roux-en-Y gastric bypass: weight loss and resolution of comorbidities at 15 years and beyond.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold-standard bariatric procedure with proven efficacy in morbidly obese populations. While the short-term benefits of LRYGB have been well-documented, durable weight loss and long-term resolution of obesity-related comorbidities have been less clearly described. METHODS: This single-center study prospectively reports weight loss and comorbidity resolution in patients undergoing LRYGB between August 2001 and September 2007 with at least 15-year follow-up. Data were collected at the time of surgery; 1, 3, 6, and 12 months postoperatively; and then annually thereafter. RESULTS: A total of 486 patients were included in this analysis. Patients were predominantly female (88.7%), and the median age was 36.0 [IQR 29.0-45.0] years. Patients were ethnically diverse, including Black/African American (43.6%), White/Caucasian (35.0%), Hispanic (18.3%), and other backgrounds (3.1%). Mean preoperative weight and body mass index were 133.0 ± 21.9 kg and 48.4 ± 6.5 kg/m2, and the median number of comorbidities was 6.0 [IQR 4.0-7.0]. Follow-up rates at 1, 5, 10, and 15 years were 75.3%, 37.2%, 35.2%, and 18.9%, respectively. On average, maximum percentage total weight loss (%TWL) occurred 2 years postoperatively (- 36.2 ± 9.5%), and ≥ 25% TWL was consistently achieved at 1, 5, 10, and 15-year time intervals (- 28.0 ± 13.0% at 15 years). Patients with comorbidities experienced improvement or resolution of their conditions within 1 year, including type 2 diabetes mellitus (83/84, 98.8%), obstructive sleep apnea (112/116, 96.6%), hypertension (142/150, 94.7%), and gastroesophageal reflux disease (217/223, 97.3%). Rates of improved/resolved comorbidities remained consistently high through at least 10 years after surgery. CONCLUSIONS: LRYGB provides durable weight loss for at least 15 years after surgery, with stable average relative weight loss of approximately 25% from baseline. This outcome corresponds with sustainable resolution of obesity-related comorbidities for at least 10 years after the initial operation.

Long-term weight loss after bariatric procedures for morbidly obese adolescents and youth: a single-institution analysis with up to 19-year follow-up.

BACKGROUND: Obesity is a public health concern among adolescents and young adults. Bariatric surgery is the most effective treatment for morbid obesity and has been increasingly utilized in young patients. Long-term outcomes data for bariatric surgery in this age group are limited. METHODS: This is a single-institution, prospective analysis of 167 patients aged 15-24 years who underwent one of three laparoscopic bariatric procedures between 2001 and 2019: Roux-en-Y gastric bypass (LRYGB, n = 71), adjustable gastric banding (LAGB, n = 22), and sleeve gastrectomy (LSG, n = 74). Longitudinal weight and body mass index (BMI) measurements were compared to evaluate patterns of weight loss. RESULTS: All operations were completed laparoscopically using the same clinical pathways. Patients were predominantly female (82.6%), had a median age of 22.0 [Q1-Q3 20.0-23.0] years, and had a mean presurgical BMI of 48.5 ± 6.5 kg/m2 (range 38.4-68.1 kg/m2). All procedures produced significant weight loss by 1 year, peak weight loss by 2 years, and modest weight regain after 5 years. Mean percent weight/BMI losses at 5 years for LRYGB, LAGB, and LSG were - 36.7 ± 10.8%, - 14.5 ± 15.3%, and - 25.1 ± 13.4%, respectively (p < 0.001). LRYGB patients were most likely to achieve ≥ 25% weight loss at 1, 3, and 5 years and maintained significant average weight loss for more than 15 years after surgery. Reoperations were procedure-specific, with LAGB, LRYGB, and LSG having the highest, middle, and lowest reoperation rates, respectively (40.9% vs. 16.9% vs. 5.4%, p < 0.001). CONCLUSION: All procedures provided significant and durable weight loss. LRYGB patients achieved the best and most sustained weight loss. LSG patients experienced second-best weight loss between 1 and 5 years, with lowest chance of reoperation. LAGB patients had the least weight loss and the highest reoperation rate. Compared to other factors, type of bariatric procedure was independently predictive of successful weight loss over time. More studies with long-term follow-up are needed.

Weight loss dynamics following laparoscopic Roux-en-Y gastric bypass. An analysis of 10-year follow-up data.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) still remains the gold-standard bariatric procedure. Short-term weight loss and improvement of type 2 diabetes mellitus (DM2) after LRYGB are well-documented. Little data are available on long-term weight loss and continued remission of DM2 in these patients. METHODS: This study reports on weight loss and remission of DM2 in 576 consecutive patients who underwent primary LRYGB between August 2001 and August 2009 with at least 10-year follow up. All patients were treated at a single institution by a single surgeon. All data were collected and entered into the database prospectively. RESULTS: A total of 576 patients were included in the study. Patients' mean age was 38.2 ± 10.9 years and females represented 88.2% of patients. Patients' ethnicity was diverse, including African Americans (44.4%), Caucasians (34.0%), Hispanics (18.1%), and 3.5% from other backgrounds. On average, there were 6.9 ± 2.7 comorbidities per patient and DM2 was initially present in 150/576 patients (26.0%). Mean preoperative weight and BMI were 132.4 ± 22.0 kg and 48.3 ± 6.7 kg/m2, respectively. Ten-year follow-up reporting rate was 145/576 (25.2%). Maximum weight loss occurred at 18 months (mean weight 83.4 ± 16.5 kg, mean BMI 30.5 ± kg/m2). At 10 years, mean weight was maintained at 94.8 ± 20.5 kg and mean BMI was 34.3 ± 6.8 kg/m2. The average weight regain between one and ten years was 8.27 kg. Among patients with preoperative DM2, continued remission of DM2 at 10 years occurred in 19/32 (59.4%) patients. CONCLUSIONS: LRYGB provides durable long-term weight loss, as well as successful remission of DM2 at 10 years. More long-term follow-up studies evaluating weight loss and comorbidities extending beyond the initial 10-year period are needed. Such studies are essential for projecting late outcomes of LRYGB, particularly in younger patients with life expectancy exceeding several decades.

Laparoscopic-guided transversus abdominis plane block following laparoscopic sleeve gastrectomy is associated with an earlier return to activity: a study of 271 patients.

BACKGROUND: The morbidly obese (MO) patient presents a unique challenge to pain control in the postoperative period due to associated comorbidities and the amplified impact of opiates. In order to reduce potential complications associated with narcotic use in the MO patient, multimodal analgesia has been advocated. In this study, we examined the effect of laparoscopic-guided transversus abdominis plane block (LG TAP) for further optimizing multimodal pain control. METHODS: This is a retrospective analysis of a prospectively collected database of 140 consecutive patients undergoing LSG without TAP block (pre-TAP group) compared to 131 patients undergoing LSG with LGTAP (TAP group). All operations were performed laparoscopically utilizing uniform clinical pathways. Baseline characteristics for both groups were comparable. Both groups received standardized anesthesia. Outcomes included time to postoperative ambulation, pain scores, PCA volume, length of hospital stay, utilization of oral opiate medications, and return to activity (RTA). RESULTS: Pre-TAP versus TAP groups were comparable, mean age 42 years (p = 0.99), women 81.4% versus 87.8% (p = 0.148), mean BMI (kg/m2) 46 versus 45 (p = 0.394). Most patients ambulated within 2 h after arrival to the floor (87.9% vs. 76.3%, p = 0.013). On postoperative day (POD) 1, mean reported pain score (0-10) was 4.50 vs. 5.06 (p = 0.063) and a mean PCA morphine used for 24 h was 26.3 mL versus 26 mL, p = 0.35. Mean days of postoperative opiate medication were 2.19 versus 1.24 (p < 0.001). Return to activity was 2.81 versus 2.08 days (p < 0.001). When controlled for age, BMI, OR time, PCA volume used, and average pain score, TAP block was an independent predictor of earlier return to activities (p < 0.001). CONCLUSIONS: LGTAP block following LSG is an additional valuable modality of pain control in the perioperative period. Our study shows that TAP block is associated with an earlier RTA and decreased opiate use in patients undergoing LSG.

Demographics and socioeconomic status as predictors of weight loss after laparoscopic sleeve gastrectomy: A prospective cohort study.

BACKGROUND: Prior studies have established that race and socioeconomic factors may influence weight loss after bariatric surgery. Few studies have focused on laparoscopic sleeve gastrectomy (LSG). The objective of this study is to determine if demographic factors may predict postoperative weight loss following LSG. METHODS: Prospectively collected data on 713 consecutive primary LSG operations performed with the same technique between February 2010 and May 2016 by a single surgeon (PG) were analyzed. Multiple regression analysis was done to determine if gender, race, or socioeconomic factors such as insurance and employment status correlated with postoperative weight loss. The presence of chronic comorbidities affecting quality of life such as Type II Diabetes and Obstructive Sleep Apnea (OSA) were also recorded and analyzed. RESULTS: All studied groups had similar preoperative body mass index (BMI) (mean 46 kg/m2). Race was not significantly associated with weight loss at any postoperative interval. Male gender was associated with increased weight loss through the first three months (48.2 ±â€¯12.5 lbs vs. 40.5 ±â€¯11 lbs; p = 0.0001). Patients with diabetes had significantly less weight loss at the 6 through 18 month intervals (50.4 ±â€¯17.9 lbs vs. 59.6 ±â€¯15.6 lbs at six months; p = 0.00032; 53.3 ±â€¯25.4lbs vs. 80.5 ±â€¯31.3lbs at 18 months; p = 0.008). Patients with obstructive sleep apnea had significantly less weight loss at the two-year interval (57.5 ±â€¯29.2 lbs) vs. those without obstructive sleep apnea (69.6 ±â€¯23.5 lbs; p = 0.047). Those with Medicare compared to Medicaid or commercial insurance had decreased weight loss through the first year (52.8 ±â€¯20.8 lbs vs. 71.4 ±â€¯26.4 lbs vs. 68.6 ±â€¯24.7 lbs; p = 0.0496). Notably, a higher percentage of patients in the Medicare insurance group were also diabetic and had OSA (65% vs. 34% vs. 36%; p = 0.002; 80% vs. 55% vs. 57%; p = 0.01). Finally, those patients who were students had the greatest weight loss at two years postoperatively with the least weight loss seen in retired patients followed by those on disability (108.0 ±â€¯21.5 lbs vs. 26.0 lbs vs. 46.0 ±â€¯19.7 lbs; p = 0.04). CONCLUSIONS: Several demographic factors including comorbidities, insurance status, and employment may significantly affect weight loss patterns following LSG. Further studies are needed to evaluate whether demographic differences impact long term weight loss. Differences in outcomes based on patient demographics may be beneficial in the planning of the allocation of healthcare resources.

Intraabdominal partitioning of the laparoscopic sleeve gastrectomy remnant optimizes the specimen extraction ergonomics and postoperative pain and is an attractive technique in teenage patients.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure in the pediatric population worldwide. The fear of complications, postoperative pain, and recovery remain the reservations for wider application of surgery in morbidly obese children. We present a novel technique for LSG remnant retrieval. MATERIALS AND METHODS: The patient was a 16-year old girl with a body mass index of 55 kg/m(2) and significant comorbidities who underwent LSG and liver biopsy. In the extraction technique, a specimen containing the gastric body and fundus, approximately 80% of the stomach volume, was partitioned longitudinally and intracorporeally with endoshears; subsequently, it was retrieved in one fragment via the lumen of a 15-mm port. RESULTS: The procedure time was 65 minutes (specimen extraction time was 7 minutes). Her recovery was uneventful, and she was discharged home on the second postoperative day. At the 1-, 3-, and 6-month follow-up, she has shown all the benefits of weight loss and associated improvement in metabolic parameters and quality of life, without any complications. CONCLUSIONS: This technique for gastric remnant retrieval results in minimizing postoperative pain, reducing operative costs, and minimizing the likelihood of wound infection.

Malignant hyperthermia during laparoscopic adjustable gastric banding.

BACKGROUND: We report a rare case of malignant hyperthermia during laparoscopic adjustable gastric banding. CASE DESCRIPTION: A 32-y-old female with no previous history of adverse reaction to general anesthesia underwent laparoscopic adjustable gastric banding. Intraoperative monitoring revealed a sharp increase in end-tidal carbon dioxide, autonomic instability, and metabolic and respiratory acidosis, along with other metabolic and biochemical derangements. She was diagnosed with malignant hyperthermia. Desflurane, the anesthetic agent was discontinued, and the patient was started on intravenous dantrolene. RESULTS: The surgery was completed, and the patient was brought to the surgical intensive care unit for continued postoperative care. She developed muscle weakness and phlebitis that resolved prior to discharge. CONCLUSION: Prompt diagnosis and treatment of malignant hyperthermia leads to favorable clinical outcome. This clinical entity can occur in the bariatric population with the widely used desflurane. Bariatric surgeons and anesthesiologists alike must be aware of the early clinical signs of this rare, yet potentially fatal, complication.

Prevalence of Helicobacter pylori infection in bariatric patients: a histologic assessment.

BACKGROUND: Studies on rates of Helicobacter pylori (HP) infection in morbidly obese patients awaiting bariatric surgery are conflicting because of small sample size and variability in diagnostic testing. The objective of this study was to determine the rate of biopsy-proven active HP infection in morbidly obese patients undergoing bariatric surgery. METHODS: Retrospective analysis was done on all morbidly obese patients who underwent bariatric surgery between 2001 and 2009. All patients underwent preoperative upper endoscopy with biopsy to evaluate HP status. All endoscopies and surgeries were performed by a single endoscopist and surgeon, respectively. Data were analyzed with Student t test, Pearson χ(2) test, and logistic regression for multivariate analysis. RESULTS: The 611 patients included 79 males (12.9%) and 532 females (87.1%). Mean age was 39.9 ± 10.7 years, and mean body mass index (BMI) was 47.8 ± 6.4 kg/m(2). The overall HP infection rate was 23.7%. Rate of infection did not differ between gender (22.8% in males, 23.9% in females; P = .479) or BMI (48.6 ± 6.5 kg/m(2) in HP-positive patients, 47.5 ± 6.4 kg/m(2) in HP-negative patients; P = .087). Patients with HP were older compared with those without infection (41.2 versus 38.7 years; P =.016). Hispanics had a higher prevalence of HP (OR 2.35; P = .023). CONCLUSION: Increasing BMI is not an independent risk factor for active HP infection within the morbidly obese patient population. Need for invasive testing to detect HP infection in these patients should be re-evaluated. Other methods of detecting active HP infection should be considered as an alternative to invasive or serologic testing.

Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database.

INTRODUCTION: Postoperative pulmonary embolism (PE) is a leading cause of morbidity and mortality after bariatric surgery. However, the concurrent prophylactic placement of an inferior vena cava filter (CPIVCF) in patients undergoing bariatric operations remains controversial. This study used the Bariatric Outcomes Longitudinal Database (BOLD) to establish associated characters and determine outcomes of CPIVCF for patients undergoing Roux-en-Y gastric bypass (GB) and adjustable gastric banding (AB) surgeries. METHODS: We analyzed BOLD, a database of bariatric surgery patient information. GB and AB operations were categorized into open and laparoscopic approaches. Univariate logistic regressions were used to compare between non-CPIVCF and concurrent CPIVCF groups. Significant variables (P < .05) were subsequently input into multivariate regression models: CPIVCF was retained in each model. RESULTS: A total of 322 CPIVCFs (0.33%) were identified from 97,218 GB and AB operations performed between 2007 and 2010 in this retrospective registry study. Significant differences were identified in male gender (21.1% vs 31.4%; P < .001), preoperative body mass index (BMI; 44.5 ± 6.6 vs 45.3 ± 7; P < .001), and African-American race (10.5% vs 18%; P < .001) between non-CPIVCF and CPIVCF groups. The CPIVCF group had more patients with previous nonbariatric surgery (50% vs 43.6%; P = .02), a history of venous thromboembolism (VTE; 21.4% vs 3.1%; P < .001), impairment of functional status (7.8% vs 3.1%; P < .001), lower extremity edema (47.2% vs 27.1%; P < .001), obesity hypoventilation syndrome (7.1% vs 2.1%; P < .001), obstructive sleep apnea syndrome (58.1% vs 43.3%; P < .001), and pulmonary hypertension (13% vs 4.1%; P < .001). Patients in the CPIVCF group were more likely to receive GB than gastric banding (77% vs 58.1%; P < .001) and an open surgical approach (21.4% vs 4.8%; P < .001). Operative duration was longer in the CPIVCF group (119 ± 67 vs 89 ± 52 minutes; P < .001). The CPIVCF group also had a longer length of hospital stay (3 ± 2 vs 2 ± 6 days; P = .048), was associated with higher incidence of deep venous thrombosis (DVT; 0.93% vs 0.12%; P < .001), and had a higher mortality (0.31% vs 0.03%; P = .003) from PE and indeterminate causes. In multivariate analysis, male gender, African-American race, previous nonbariatric surgery, a high BMI, obesity hypoventilation syndrome, history of VTE, lower extremity edema, and pulmonary hypertension were preoperative factors associated with CPIVCF. CONCLUSIONS: CPIVCF was associated with specific clinical features, increased health care resource utilization, and a higher mortality in patients undergoing bariatric operations. Although selected patient characteristics influence surgeons to perform CPIVCF, this study was unable to establish an outcome benefit for CPIVCF.

Laparoscopic adrenalectomy for bilateral metachronous aldosteronomas.

INTRODUCTION: Primary aldosteronism affects 5% to 13% of patients with hypertension. Idiopathic bilateral hyperplasia (IHA) and unilateral aldosterone-producing adenoma (APA) are the most common types of primary aldosteronism. Bilateral APA is a very rare entity with only a few reports in the literature. We present the case of a patient with metachronous bilateral APA treated with metachronous bilateral total and near total adrenalectomy. CASE REPORT: A 66-year-old female was evaluated for hypokalemia and hypertension refractory to medical therapy 2 years after laparoscopic adrenalectomy for right APA. Follow-up abdominal CT scan revealed a new 1.1-cm left adrenal mass. The patient underwent a laparoscopic near total adrenalectomy for her new left adrenal mass. Pathology examination revealed a new APA. The operation and the patient's postoperative course were uneventful. Potassium levels were normalized and her hypertension became well controlled. CONCLUSION: APA can present metachronously months to years after adrenalectomy for APA in the contralateral adrenal gland. Laparoscopic adrenalectomy remains the approach of choice for this pathology.

Laparoscopic appendectomy is the preferred approach for appendicitis: a retrospective review of two practice patterns.

BACKGROUND: This study aimed to compare the results of laparoscopic appendectomy (LA) and open appendectomy (OA). METHODS: A retrospective analysis of 264 patients who underwent appendectomy (155 LA and 109 OA) over an 8-year period was performed. The variables analyzed included patient data (white blood cell count [WBC], duration of symptoms, American Society of Anesthesiology [ASA] score), operating data (length of the procedure and pathology), postoperative data (postoperative complications and length of hospital stay), and total costs. RESULTS: Patient demographic data (age and sex), preoperative WBC, duration of symptoms, and pathology all were similar in the two study groups. Six cases were converted to OA and included in the LA group data. There was no statistical difference in the average operative time between the LA (mean, 55.7 + or - 22.3 min; range, 20-128 min) and OA (mean, 58.9 + or - 23.7 min; range, 29-135 min) groups (95% confidence interval [CI] -8.8-2.43; p = 0.26). The overall incidence of minor and major complications was significantly less in the LA group (3.2%, five incidents) than in the OA group (17.4%, 19 incidents; p = 0.0043). The median length of hospital stay (LOS) was significantly shorter in the laparoscopic group (median, 2 days; range, 1-8 days) than in the open group (median, 3 days; range, 1-11 days; p < 0.001). The mean total cost was $5,663 in the laparoscopic group and $6,031 in the open group (non-significant difference of -$368; 95% CI, -$926-$190; p = 0.19). CONCLUSION: The findings show that LA is associated with fewer complications and similar total costs compared with OA. Therefore, LA can be recommended as a preferred approach to appendectomy.

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.

Early lap-band erosion associated with colonic inflammation: a case report and literature review.

INTRODUCTION: Laparoscopic adjustable gastric banding is an effective and safe surgical modality for the treatment of morbid obesity. Erosion of the band into the stomach has been reported. No reports are available on erosion of the Lap-Band following diverticulitis of the colon. CASE REPORT: A 31-year-old female with a body mass index (BMI) of 52 underwent an uneventful laparoscopic Lap-Band placement. Postoperative contrast study revealed good positioning of the band and no evidence of leakage. The patient's recovery was uneventful except for an elevated temperature of 101.5 degrees F that was attributed to her atelectasis. She had lost 52 lbs. and remained asymptomatic for 3 months. Following this period of successful weight loss, she presented with complaints of abdominal pain for 3 days associated with diarrhea of 7 days' duration. A Gastrografin contrast study showed no evidence of a leak or band slippage but erosion was suspected. Upper endoscopy confirmed erosion of the band into the stomach. Computed tomography (CT) of the abdomen revealed thickening of the sigmoid and descending colon with mesenteric fat stranding consistent with diverticulitis. Laparoscopic removal of the Lap-Band system was performed. CONCLUSION: We postulate that colonic diverticulitis could have been a precipitating factor in the development of band erosion. Intraabdominal sepsis resulting in subacute infection of the Lab-Band system may be the underlying factor.

DRG, costs and reimbursement following Roux-en-Y gastric bypass: an economic appraisal.

BACKGROUND: There is disagreement regarding hospital and physician reimbursement fees when DRG codes are used. We have found that physicians and hospitals are rewarded differently depending on the type of insurance coverage - per diem HMO (Health Maintenance Organization) vs public. METHODS: 133 patients were retrospectively analyzed in a single institution. There were 59 privately-insured and 74 publicly-insured patients. Using DRG 288, hospital and surgeon reimbursement rates, complications, length of stay, blood loss and basic demographics were evaluated on all patients. Reimbursement rates were then compared to inpatient hospital costs per case for both open and laparoscopic Roux-en-Y gastric bypass (RYGBP). Statistical analysis used Student's t-test and standard deviation. RESULTS: The 2 groups were similar in terms of age, sex and BMI. There was a large difference in physician reimbursement when comparing public to private insurance (931 US dollars +/-73 vs 2356 US dollars +/-822, P<0.001). Likewise, there was a large difference in hospital reimbursement (public 11773 US dollars +/- 4462 vs private 4435 US dollars +/- 3106, P<0.001). The estimated costs for open gastric bypass was 3179 US dollars vs 4180 US dollars for the laparoscopic bypass. The HMO per diem rate was 1000 US dollars per day. CONCLUSION: There is a relative disincentive for surgeons to treat publicly-insured patients, while there is an incentive for hospitals to treat those patients. The converse is true for the privately-insured patients. This dichotomy will impede the development of new centers and place greater burden on bariatric surgeons to reduce cost by performing the open RYGBP.

Emergent laparoscopic reduction of acute gastric volvulus with anterior gastropexy.

Gastric volvulus is characterized by abnormal rotation of the stomach around an axis made by two fixed portions. Symptoms of gastric volvulus range from anemia and weight loss to severe epigastric or chest pain associated with nonproductive vomiting or upper gastrointestinal bleeding. Ischemia, necrosis, and perforation will occur if this condition remains untreated. We report a case of a 92-year-old patient with acute gastric volvulus treated with laparoscopic reduction and anterior gastropexy. We suggest that the laparoscopic approach to gastric volvulus is safe and feasible and should be considered. High-risk and elderly patients can particularly benefit from minimally invasive access. Anterior gastropexy palliates the symptoms and can be considered a definitive treatment in this patient population.