Safety and outcomes of performing laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy at an ambulatory site of a tertiary care hospital in Ontario.

BACKGROUND: In Ontario, bariatric surgery is publicly funded and is performed only in accredited tertiary care hospitals. The purpose of our study was to report on the safety and outcomes of performing bariatric surgery at an ambulatory site of a tertiary care hospital in southern Ontario. METHODS: We conducted a retrospective cohort study of all adult (age ≥ 18 yr) patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) at the ambulatory site of our tertiary care hospital between September 2016 and August 2018. The 2 sites are 1.4 km apart. Patient demographic characteristics, duration of surgery, intraoperative and 90-day postoperative complications, number of transfers and readmission to the tertiary care hospital, and emergency department visits were collected. RESULTS: A total of 314 patients (285 women [90.8%] and 29 men [9.2%] with a mean age of 41.8 yr [standard deviation (SD) 8.9 yr]) underwent surgery: LRYGB in 295 cases (93.9%) and LSG in 19 (6.0%). The mean body mass index was 45.3 (SD 5.1), the median American Society of Anesthesiologists score was 3 (range 2-4), and the median Edmonton Obesity Staging System score was 2 (range 0-4). The mean operative time was 119.8 (SD 23.1) minutes for LRYGB and 96.2 (SD 22.0) minutes for LSG, and the mean length of stay was 2.1 (SD 0.6) days and 2.1 (SD 0.2) days, respectively. Thirteen patients (4.1%) required transfer to the tertiary care hospital for a postoperative complication. Of 312 patients, 29 (9.3%) presented to emergency department within 90 days after surgery, and 8 (2.6%) required readmission to hospital; no deaths were reported. CONCLUSION: The findings suggest that LRYGB and LSG can be performed safely at an ambulatory site of a tertiary care hospital. However, caution should be exercised in performing these procedures at an ambulatory site without a tertiary care hospital affiliation, as patients may require urgent transfer for a serious postoperative complication.

Computational modelling of self-reported dietary carbohydrate intake on glucose concentrations in patients undergoing Roux-en-Y gastric bypass versus one-anastomosis gastric bypass.

OBJECTIVES: Our aim was to investigate in a real-life setting the use of machine learning for modelling the postprandial glucose concentrations in morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGB) or one-anastomosis gastric bypass (OAGB). METHODS: As part of the prospective randomized open-label trial (RYSA), data from obese (BMI ≥35 kg/m2) non-diabetic adult participants were included. Glucose concentrations, measured with FreeStyle Libre, were recorded over 14 preoperative and 14 postoperative days. During these periods, 3-day food intake was self-reported. A machine learning model was applied to estimate glycaemic responses to the reported carbohydrate intakes before and after the bariatric surgeries. RESULTS: Altogether, 10 participants underwent RYGB and 7 participants OAGB surgeries. The glucose concentrations and carbohydrate intakes were reduced postoperatively in both groups. The relative time spent in hypoglycaemia increased regardless of the operation (RYGB, from 9.2 to 28.2%; OAGB, from 1.8 to 37.7%). Postoperatively, we observed an increase in the height of the fitted response curve and a reduction in its width, suggesting that the same amount of carbohydrates caused a larger increase in the postprandial glucose response and that the clearance of the meal-derived blood glucose was faster, with no clinically meaningful differences between the surgeries. CONCLUSIONS: A detailed analysis of the glycaemic responses using food diaries has previously been difficult because of the noisy meal data. The utilized machine learning model resolved this by modelling the uncertainty in meal times. Such an approach is likely also applicable in other applications involving dietary data. A marked reduction in overall glycaemia, increase in postprandial glucose response, and rapid glucose clearance from the circulation immediately after surgery are evident after both RYGB and OAGB. Whether nondiabetic individuals would benefit from monitoring the post-surgery hypoglycaemias and the potential to prevent them by dietary means should be investigated.KEY MESSAGESThe use of a novel machine learning model was applicable for combining patient-reported data and time-series data in this clinical study.Marked increase in postprandial glucose concentrations and rapid glucose clearance were observed after both Roux-en-Y gastric bypass and one-anastomosis gastric bypass surgeries.Whether nondiabetic individuals would benefit from monitoring the post-surgery hypoglycaemias and the potential to prevent them by dietary means should be investigated.

Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Introduction: after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy. Objective: this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account. Materials and methods: a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation. Results: of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05). Conclusions: endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain.

INTRODUCCIÓN: Introducción: tras un baipás gástrico laparoscópico en "Y de Roux" muchos pacientes refieren dolor epigástrico o intolerancia alimenticia, lo que motiva la realización de una endoscopia digestiva alta. Objetivos: el objetivo de este estudio es intentar establecer una relación entre la sintomatología referida por los pacientes sometidos a baipás gástrico con los hallazgos endoscópicos patológicos y conocer qué factores pueden estar implicados, considerando el momento de presentación. Material y métodos: estudio retrospectivo de cohortes, identificando a los pacientes sometidos a baipás gástrico laparoscópico que presentan dolor epigástrico o intolerancia alimenticia durante el seguimiento y a los que se realizó una endoscopia digestiva alta. El objetivo primario es relacionar los hallazgos endoscópicos con la sintomatología y el momento de aparición. Resultados: de los 514 pacientes que presentaban dolor epigástrico o intolerancia alimenticia, 81 (15,6 %) fueron sometidos a endoscopia digestiva alta. En un 58 % de los casos se encontraron complicaciones relacionadas con la gastroyeyunostomía. En todos los pacientes que presentaban simultáneamente dolor e intolerancia aparecieron hallazgos endoscópicos patológicos. El único factor preoperatorio relacionado con las complicaciones fue el hábito tabáquico (p = 0,021). El tiempo entre la cirugía y la realización de la endoscopia también fue un factor significativamente relacionado con los hallazgos endoscópicos (p = 0,007). En los casos de dolor epigástrico durante el primer año (media: 10 meses) existía un incremento del riesgo de aparición de complicaciones de la gastroyeyunostomía (p < 0,05). Conclusiones: las endoscopias realizadas durante el primer año postoperatorio tenían más probabilidades de presentar hallazgos patológicos, sobre todo en los pacientes afectos de dolor epigástrico.

The yield, effectiveness and safety of gastroscopy in management of early postbariatric upper gastrointestinal pain.

BACKGROUND: Upper gastrointestinal (GI) symptoms are prevalent among patients after -bariatric surgeries. Gastroscopy is an important procedure to investigate symptoms. Our primary aim was to evaluate the yield, effectiveness and safety of gastroscopy procedure obtained in a 3-months period after bariatric operation for exploring upper GI symptoms origin. METHODS: Single center, retrospective study at the EMMS Nazareth Hospital from 2010 to 2018. All patients who underwent gastric-bypass (either Roux-en-Y[R-en-Y] or Mini-gastric bypass [MGB]) and who experienced early upper GI symptoms were included in the study. RESULTS: A total of 428 were included in the study. Among them, 154 patients (36%) underwent R-en-Y surgery and 274 (64%) underwent MGB. Baseline characteristics were similar in the two groups. The mean age in the R-en-Y group was 42.3±10.8 vs. 42.8±11.2 in the MGB group. Thirty-nine patients underwent gastroscopy, more in the R-en-Y group compared to MGB group (11.6% vs. 7.6%, P<0.005). In the MGB group, more patients had normal surgical anatomy (23.1%) vs. 12.8% in the R-en-Y group, and the prevalence of erosive esophagitis was 14.2% in the MBG group vs. 5.5% in the R-en-Y group, P<0.005. On the other hand, marginal ulcer was more frequent after R-en-Y than MGB surgery (16.6% vs. 9.5%, P<0.005). No procedural related complication was observed in both groups. CONCLUSIONS: Upper GI symptoms in the early postbariatric surgery period are common with most endoscopic examination revealing normal postsurgical anatomy. In this setting, gastroscopy is safe, without procedural related complications.

Epidemiology and risk factors for invasive fungal disease in liver transplant recipients in a tertiary transplant center.

BACKGROUND: Invasive fungal disease (IFD) in liver transplant recipients causes significant morbidity and mortality. We aim to describe institutional epidemiology and risk factors for IFD in the liver transplant population. METHODS: We conducted a retrospective cohort study of all adult liver transplant recipients in our institution from 2005 to October 2015 to describe the epidemiology of patients with proven and probable IFD according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. To determine risk factors for IFD, a case-control study was also conducted. Cases were defined as liver transplant recipients with proven or probable IFD, and controls were defined as liver transplant recipients without IFD. Each case was matched to two controls by age (±10 years of age), gender, and time of transplant (within one year of the case). RESULTS: 28/554 (5.1%) patients developed IFD. Candidiasis (n = 11; 39.3%), Aspergillosis (n = 10; 35.7%), and Cryptococcosis (n = 3; 10.7%) were the most common fungal infections in the proven and probable IFD groups. Mold infections occurred in 13 (46.4%) cases. Reoperation, roux-en-y anastomosis, and massive intraoperative transfusion of ≥40 units of cellular blood products were major risk factors for IFD in the multivariate analysis. CONCLUSION: Candida and Aspergillus are the most common causes of IFD in liver transplantation in our center. There is significant overlap in risk factors for such infections post-transplantation. In our cohort, critically ill patients with complicated perioperative course seem to predispose them to mold infections post-transplantation, but larger studies are required to better delineate risk factors for mold infection as well as determine the efficacy and optimal duration of mold prophylaxis in liver transplantation. With increasing echinocandin use for antifungal prophylaxis, it is also important to monitor for emerging antifungal resistance.

Uncut Roux-en-Y Reconstruction in a Laparoscopic Distal Gastrectomy: A Single-Center Study of 228 Consecutive Cases and Short-Term Outcomes.

Aims. We have established a procedure for uncut Roux-en-Y gastrojejunostomy after laparoscopic distal gastrectomy. This study aimed to evaluate the safety and technical feasibility of the procedure for patients with distal gastric cancer according to the short-term outcomes. Methods. Two hundred and twenty-eight consecutive patients who underwent a laparoscopic distal gastrectomy with uncut Roux-en-Y gastrojejunostomy from September 2014 to August 2018 were reviewed retrospectively. All the laparoscopic operations were performed successfully without conversion to open surgery. Results. The mean operative duration was 178.28 ± 32.82 minutes, the mean anastomotic process duration was 28.22 ± 7.50 minutes, the average blood loss was 48.97 ± 29.16 mL, and the overall number of lymph nodes harvested was 37.16 ± 11.47. The mean time of out-of-bed ambulation, anal exsufflation, liquid-diet intake, and duration of hospital stay were 41.99 ± 18.37 hours, 69.57 ± 23.17 hours, 5.06 ± 1.09 days, and 8.77 ± 2.42 days, respectively. Fifteen patients suffered postoperative complications, and the overall incidence rate was 6.58% (15/228). Seventeen patients experienced afferent recanalization, the mean time of which was 11 months after the operation. Conclusion. The laparoscopic uncut Roux-en-Y reconstruction is safe and technically feasible, and it has inspiring short-term outcomes for patients undergoing distal gastrectomy.

Randomized trial of two types of gastrojejunostomy after pancreatoduodenectomy and risk of delayed gastric emptying (PAUDA trial).

BACKGROUND: Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. METHODS: This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. RESULTS: A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. CONCLUSION: The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).

Metabolic comparison of one-anastomosis gastric bypass, single-anastomosis duodenal-switch, Roux-en-Y gastric bypass, and vertical sleeve gastrectomy in rat.

BACKGROUND: One-anastomosis gastric bypass (OAGB) and single-anastomosis duodenal switch (SADS) have become increasingly popular weight loss strategies. However, data directly comparing the effectiveness of these procedures with Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (SG) are limited. OBJECTIVES: To examine the metabolic outcomes of OAGB, SADS, RYGB, and SG in a controlled rodent model. SETTING: Academic research laboratory, United States. METHODS: Surgeries were performed in diet-induced obese Long-Evans rats, and metabolic outcomes were monitored before and for 15 weeks after surgery. RESULTS: All bariatric procedures induced weight loss compared with sham that lasted throughout the course of the study. The highest percent fat loss occurred after OAGB and RYGB. All bariatric procedures had improved glucose dynamics associated with an increase in insulin (notably OAGB and SADS) and/or glucagon-like protein-1 secretion. Circulating cholesterol was reduced in OAGB, SG, and RYGB. OAGB and SG additionally decreased circulating triglycerides. Liver triglycerides were most profoundly reduced after OAGB and RYGB. Circulating iron levels were decreased in all surgical groups, associated with a decreased hematocrit value and increased reticulocyte count. The fecal microbiome communities of OAGB, SADS, and RYGB were significantly altered; however, SG exhibited no change in microbiome diversity or composition. CONCLUSIONS: These data support the use of the rat for modeling bariatric surgical procedures and highlight the ability of the OAGB to meet or exceed the metabolic improvements of RYGB. These data point to the likelihood that each surgery accomplishes metabolic improvements through both overlapping and distinct mechanisms and warrants further research.

Comparative Analysis of Immediate Postoperative Complications Following Total Gastrectomy.

INTRODUCTION: Total gastrectomy (TG), despite disrupting the continuity of the alimentary tract and accounting for significant postoperative complications, is the procedure of choice for curative resection of gastric carcinoma. The objectives of this study were to report the rate of postoperative complications following TG, to analyze adverse postoperative outcomes, and to determine which of the two techniques - the Roux-en-Y esophagojejunostomy and Omega-Braun TG, is safer. MATERIALS AND METHODS: A retrospective, observational study was conducted among patients diagnosed with gastric carcinoma who underwent TG between January 1st, 2010 and December 31st, 2012 in the Surgery Department of the Bucharest Clinical Emergency Hospital. Descriptive and analytical statistical analysis with parametric and non-parametric tests was carried out using GraphPad, with statistical significance set at p <0.05. RESULTS: Seventy-seven patients, aged 37-91 years (average age 64.1 ± 11.59 years), were enrolled in this study. A total of 84 immediate postoperative complications were encountered in 35 patients (47.5%), classified into local (n=21, 25%) and general complications (n=63, 75%). Reoperation was necessary in five cases (6.2%), all after Roux-en-Y end-side esophagojejunostomy. Two deaths (n=2, 2.5%), one after Roux-en-Y and one after Omega-Braun TG, were reported. DISCUSSION: The Roux-en-Y technique had a higher number of complications, both local and general. Omega-Braun TG was associated with a lower number of local complications; however, it was associated with life-threatening complications including hemodynamic instability and multisystem organ failure. CONCLUSION: The study deemed Roux-en-Y Esophagojejunostomy the overall safer procedure. A statistically significant correlation between manual anastomosis and mortality was observed. Total Gastrectomy is a complex procedure with numerous potential complications which calls for an improved surgical technique to reduce postoperative risk.

Spending on Bariatric Surgery in the Unified Health System from 2010 to 2014: a Study Based on the Specialist Hospitals Authorized by the Ministry of Health.

BACKGROUND: The aim of this study is to analyze the production of 76 specialist hospitals for the morbidly obese in Brazil's public healthcare system (SUS) from 2010 to 2014 in terms of quantity and costs of bariatric surgery and its complications. METHODS: Secondary data from the SUS Hospital Information System and the National Healthcare Establishments Registry were used. Current spending on bariatric surgery and its medical and postoperative complications were analyzed. RESULTS: There was a 60 % rise in the number of surgeries between 2010 and 2014. This increase was not homogeneous among the hospitals studied, since only 19 performed the minimum number of surgeries required. Women accounted for 85 % of the surgeries carried out, and 32 % were aged between 35 and 44 years. The Roux-en-Y technique was the most widely used (93.7 % of the total), followed by sleeve gastrectomy. The ratio between the occurrence of medical complications and total number of surgeries performed in each hospital varied significantly (between 0 and 5.97 %) but was lower for postoperative complications, ranging from 0 to 1.7 %. There was a nominal increase of 44 % in average expenditure on postoperative complications between 2013 and 2014, while the average cost of medical complications decreased by 8.7 % in the same period. CONCLUSIONS: Despite the rise in the number of bariatric surgeries in Brazil, there is still a high demand for surgeries that is not being met, while most specialist hospitals fail to perform the minimum number of surgeries stipulated by the Ministry of Health.

Maximizing Weight Loss After Roux-en-Y Gastric Bypass May Decrease Risk of Incident Organ Cancer.

BACKGROUND: Recent studies have suggested that metabolic surgery reduces cancer risk. This study aims to determine if incident cancer is associated with the extent of weight loss after Roux-en-Y gastric bypass (RYGB). METHODS: Patients at a large tertiary bariatric surgery center were retrospectively reviewed to identify patients with no history of cancer at the time of RYGB. Diagnoses in the electronic health record, a tumor registry, and chart review were used to identify postoperative incident solid organ cancer. The overall incidence of organ cancer was estimated using Kaplan-Meier analysis. The percent total body weight loss (%TWL) in the 48 months after surgery but prior to cancer was compared between those that developed organ cancer versus those that did not using repeated measures linear regression. RESULTS: The 2943 patients had a mean age of 45.6 years (SD = 11.1), 81 % were female, and a mean baseline body mass index (BMI) of 47.2 kg/m2 (SD = 7.9). Median follow-up after surgery was 3.8 years (range = [<1, 12]). Incident organ cancer developed and was verified in 54 of the 2943 patients (1.8 %). Kaplan-Meier estimates for cancer at 3, 5, and 10 years postsurgery were 1.3, 2.5, and 4.2 %. After adjusting for age, BMI, sex, diabetes, hypertension, and dyslipidemia, patients that developed organ cancer achieved less weight loss (-1.5 % TWL, 95 % CI = [-2.9 %, -0.1 %], p = 0.034). CONCLUSIONS: Greater weight loss after metabolic surgery may be associated with lower organ cancer risk.

Clinical course of diabetes after gastrectomy according to type of reconstruction in patients with concurrent gastric cancer and type 2 diabetes.

BACKGROUND: This study was conducted to evaluate course of diabetes after gastrectomy according to type of reconstruction performed for gastric cancer in patients with type 2 diabetes. METHODS: In total, 292 patients with concurrent gastric cancer and type 2 diabetes who underwent curative surgery from January 2000 to December 2010 were enrolled in this retrospective study. No surgery-related complications, tumor recurrence, or distant metastasis occurred within 2 years after surgery. The patients' clinical characteristics were compared according to reconstruction type. Their diabetes status was assessed 1, 6, 12, and 24 months postoperatively. RESULTS: Of the 292 patients, 126 underwent distal gastrectomy with Billroth I reconstruction, 103 underwent distal gastrectomy with Billroth II reconstruction, and 63 underwent total gastrectomy with Roux-en-Y reconstruction. The operation type was significantly correlated with the outcome of type 2 diabetes mellitus 2 years postoperatively (P < 0.05), while sex, age at operation, duration of diabetes, anti-diabetes treatment method, preoperative body mass index, preoperative fasting blood glucose level, and preoperative diabetes control were not (P > 0.05). The rate of remission and improvement was significantly different at 1, 6, 12, and 24 months postoperatively in the Billroth I group (P < 0.05), but not in the Billroth II group (P > 0.05). CONCLUSIONS: Patients with concurrent gastric cancer and type 2 diabetes can exhibit remission of diabetes after gastrectomy. Total gastrectomy with Roux-en-Y reconstruction was associated with the highest remission rate, while distal gastrectomy with Billroth I reconstruction showed a variable rate of remission and improvement postoperatively.

Questionnaire survey regarding the current status and controversial issues concerning reconstruction after gastrectomy in Japan.

The Japanese Society for the Study of Postoperative Morbidity after Gastrectomy conducted a nationwide questionnaire survey to clarify the current status of reconstruction after gastrectomy. One hundred and forty-five institutions (66%) responded to the survey. The questionnaire dealt with the reconstruction after a distal gastrectomy, pylorus-preserving gastrectomy (PPG), total gastrectomy, and proximal gastrectomy. The most common method of reconstruction after distal gastrectomy was Billroth I in 112 institutions (74%), and Roux-en-Y (RY) in 30 (21%). Seventy-seven institutions (53%) responded to the PPG questions. The lengths of the antral cuff were widely distributed among the institutions. Segmental gastrectomy was performed by 23 institutions for limited cases. The most common method of reconstruction after total gastrectomy was RY in 138 institutions (95%). Reconstruction with a pouch after total gastrectomy was done in 26 institutions (18%). The most common reconstructions after proximal gastrectomy were esophagogastrostomy in 69 institutions (48%), jejunal interposition in 41 (28%), double tract in 19 (13%) and pouch reconstruction in 6 (7%). Although most Japanese surgeons are concerned about the revised methods of reconstruction and quality of life after gastrectomy, surgeons have not yet reached a full consensus on these issues.

The use, safety and cost of bariatric surgery before and after Medicare's national coverage decision.

OBJECTIVE: To determine the impact of the Centers for Medicare and Medicaid Services' (CMS) bariatric surgery national coverage decision (NCD) on the use, safety, and cost of care CMS beneficiaries. BACKGROUND: In February 2006, the CMS issued a NCD restricting reimbursement for bariatric surgery to accredited centers and including coverage for laparoscopic adjustable gastric band (LAGB). METHODS: A pre/postinterrupted time-series cohort study using nationwide Medicare data (2004-2008) evaluating rates of bariatric procedures/100,000 enrollees, 90-day mortality, readmission rate and payments. RESULTS: Forty-seven thousand thirty patients underwent procedures at 928 sites pre-NCD and 662 post-NCD. The procedure rate/100,000 patients dropped after the NCD to 17.8 (from 21.9 in 2005) increasing to 23.8 and 29.1 in 2007 and 2008, respectively. Open roux-en-y gastric bypass (ORYGB) and laparoscopic roux-en-y gastric bypass (LRYGB) were common pre-NCD (56.0% ORYGB, 35.5% LRYGB) changing post-NCD with LAGB inclusion (12.8% ORYGB, 48.7% LRYGB, 36.7% LAGB). 90-day mortality pre-NCD was 1.5% (1.8% ORYGB, 1.1% LRYGB) and post-NCD was 0.7% (1.7% ORYGB, 0.8% LRYGB, 0.3% LAGB; P < 0.001). The 90-day rates of readmission decreased post-NCD (19.9% to 15.4%), reoperation (3.2% to 2.1%) and payments ($24,363 to $19,746; P for all <0.001). Differences in outcome and cost were largely explained by a shift in procedure type and patient characteristics. CONCLUSIONS: The NCD was associated with a temporary reduction in procedure rate and a shift in types of procedures and patients undergoing bariatric surgery. It was associated with a significant decrease in the risk of death, complications, readmissions, and per patient payments.

Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction: evolution in a totally intracorporeal technique.

INTRODUCTION: Laparoscopic gastrectomy is gaining popularity. Increasingly, Roux-en-Y reconstruction after distal gastrectomy is preferred because of reduced reflux and associated symptoms. Therefore, efficient and reliable techniques for intracorporeal Roux-en-Y reconstruction are in demand. AIMS: To determine the surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction in the treatment of gastric cancer. PATIENTS AND METHODS: Laparoscopic gastrectomy is indicated for gastric cancer up to stage T1N1. Our technique for laparoscopic Roux-en-Y reconstruction incorporates intracorporeal-stapled gastrojejunostomy with extracorporeal hand-sewn jejunojejunostomy, or more recently, totally intracorporeal reconstruction. RESULTS: From 2003 to 2009, 82 patients underwent laparoscopic distal gastrectomy with Roux-en-Y reconstruction. The mean age of the patients was 64.6 years (range, 39 to 83 y) and the male:female ratio was 2.4:1. Most patients (85%) had stage I disease. The mean operation time was 354 minutes (SD 82.7). The conversion rate was 0%. The mean lymph node yield was 27.2 nodes (SD 12.4). Eleven patients had totally intracorporeal reconstruction. Overall, anastomotic leakage of the gastrojejunostomy occurred in 2 patients (2.4%) both requiring reoperation. There were 2 cases (2.4%) of duodenal stump leakage, which were treated conservatively. Postoperative stasis was encountered in 2 patients (2.4%). The mean follow-up was 21 months (range, 5 to 50 mo). None of the patients developed reflux symptoms or endoscopic evidence of reflux during follow-up. Recurrence occurred in 1 patient who was the only patient with metastasis to the third tier of lymph nodes. CONCLUSIONS: Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction were acceptable in the context of early gastric cancer. Totally intracorporeal reconstruction was technically feasible, safe, and associated with no obvious drawbacks.

The effect of restrictive bariatric surgery on urinary stone risk factors.

OBJECTIVES: Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass (RYGB) place patients at risk for developing kidney stones. Stone risk factors after purely restrictive procedures such as gastric banding and sleeve gastrectomy are not well characterized. Therefore, we performed a study to examine urinary risk factors of patients who underwent restrictive gastric surgery for bariatric indications. METHODS: A total of 18 patients were enrolled in the study; 14 underwent gastric banding and 4 underwent sleeve gastrectomy. All subjects collected 24-hour urine specimens; at least 6 months had elapsed between surgery and urine collection. Standard stone risk parameters were assessed, and comparisons were made with a group of normal adult nonstone-formers, routine stone-formers, and RYGB bariatric surgery subjects. RESULTS: Urinary oxalate excretion of the restrictive cohort was significantly less than the RYGB cohort (35.4 vs. 60.7 mg/d; P <.001) and not significantly different from that of the normal subjects (32.9 mg/d; P = .798) and routine stone-formers (37.2 mg/d; P = .997). There were no other significant differences in urinary parameters. CONCLUSIONS: Restrictive bariatric surgery does not appear to be associated with an increased risk for kidney stone disease. In particular, urinary oxalate levels were significantly less than those of RYGB subjects and not significantly different from routine stone-formers and nonstone-forming controls.

Transoral technique for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) can accelerate learning curve and reduce cost.

BACKGROUND: The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure. METHODS: We compared 60 consecutive morbidly obese patients who underwent laparoscopic RYGBP. First 30 cases were performed by transabdominal anvil insertion, followed by 30 cases using transoral anvil insertion. All of the transabdominal cases were assisted by experienced fellows. The first ten transoral cases were assisted by experienced fellows and the remaining 20 by new fellows in order to evaluate if the transoral technique shortens the learning curve. Surgery duration and operative costs were compared. Complications (bleeding, leaks, anastomotic strictures, ulcers, wound infections) and length of stay were also evaluated. Data are expressed as mean +/- SD. RESULTS: Mean operative time was shorter in the transoral group compared with the transabdominal group (162.2 +/- 35.8 vs. 186 +/- 33.6 min respectively, p = 0.01), even though most of the transoral cases (n = 20) were assisted by new fellows and all of the transabdominal cases by experienced fellows. Operative times were not different between new and experienced fellows in the transoral technique. Supply costs per patient were higher in the transabdominal technique compared with the transoral technique (2,983.5 +/- 540.9 vs. 2,658.8 +/- 474.4 USD, respectively, p = 0.03). Perioperative complications and length of stay were not statistically different. CONCLUSION: The transoral introduction of the anvil of the circular stapler into the gastric pouch is a simple, safe, and efficient technique for creating the gastrojejunostomy in laparoscopic RYGBP. In addition, the transoral technique is less expensive and appears to accelerate the learning curve compared with the transabdominal technique.

[Laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity. Experience at the Nacional de Ciencias Médicas y Nutrición Salvador Zubirán]. / Bypass gástrico laparoscópico en Y de Roux y obesidad mórbida. Experiencia en el Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.

INTRODUCTION: Morbid obesity is a serious health problem associated to a significant reduction in life expectancy. OBJECTIVE: To evaluate the anthropometric and metabolic changes observed in obese patients, 3, 6 and 12 months after laparoscopic Roux-en-Y gastric bypass surgery and the complications associated with the procedure. MATERIAL AND METHODS: Retrospective study that included 128 consecutive obese patients submitted for bariatric surgery at the INCMNSZ (2004-2006). RESULTS: Their mean age was 38 +/- 10 years, 83% were women with a BMI of 48 +/- 6 Kg/m2. 65% were hypertensives, 55% had hypertriglyceridemia and 34% diabetes. A year after surgery all patients had at least reduced 20% their body weight and the percentage of excess body weight loss was 73%. The prevalence of hypertension, hypertrigliceridemia and diabetes was reduced to 24%, 17% and 12%, respectively (p < 0.001). Four patients died (3%), all of them had a leak of the anastomosis and intra-abdominal abscess. One died because pulmonary embolism, another with a myocardial infarction (after surgical reinterventions) and the other two with sepsis. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass surgery in morbid obese patients favors significant reductions in body weight and associated co morbidities. This surgery is not free of complications and mortality, reason why it must be done only by surgical and interdisciplinary groups with experience in these procedures.

Ethnic differences in obesity and surgical weight loss between African-American and Caucasian females.

BACKGROUND: In the general population, African-American females are more obese and resistant to weight loss than Caucasian women. In the present study, we examined the severity of obesity among morbidly obese African-American and Caucasian females, studied the effectiveness of Roux-en-Y gastric bypass (RYGBP), and sought to identify factors contributing to obesity and weight loss. METHODS: The study population included 153 morbidly obese females randomly selected from our general bariatric patient population. Anthropometric measurements consisted of body weight, body mass index (BMI), excess weight, and waist, hip, thigh, and neck circumferences. Factors that may contribute to obesity included age, age of obesity onset, number of childbirths, calorie intake, diet composition, and degree of psychological distress. The effects of RYBGP were studied in weight-matched groups of African-American and Caucasian females (n=37 per group) at weight loss nadir, i.e. 12 to 18 months after surgery. RESULTS: We found that morbid obesity is more severe among African-American than Caucasian females. The greater degree of obesity of African-American, as compared to Caucasian, females is not due to ethnic differences in calorie intake, diet composition, age or age of obesity onset, number of childbirths, and psychological distress. RYGBP is less effective in reducing body fat and, consequently, excess body weight of the African-American than the Caucasian females, suggesting possible ethnic differences in fat metabolism. CONCLUSION: African-American females with morbid obesity have greater adiposity than do Caucasian women and lose significantly less body fat after RYGBP.

Bariatric surgery in Poland from 1993 to 2003.

Morbid obesity affects about 300, 000 patients in Poland. The number and type of bariatric procedures performed between 1993 and 2003 has been based on data collected from Polish surgeons active in this field. During the years 1993 - 2003, 1285 primary bariatric procedures were performed in total. Amongst these 79.1% were, commonly done as restrictive ones, including vertical banded gastroplasty-76.3%, laparoscopic adjustable gastric banding-17.7% and silastic ring vertical gastroplasty-5.5% and at last non-adjustable gastric band with 0.5%. Less popular are malabsorptive procedures - 20.9%, with Roux-en-Y gastric bypass - 79.1% and biliopancreatic diversion 20.9%. During last year 2003: malabsorptive procedures represented one third of all primary procedures and the laparoscopic approach was utilised in 18 % of operations. 61 revisions were reported. There are only three centres with experience in treating more than 100 patients (one of them treated over 600). Two centres have experience in carrying out bariatric surgery for longer than five years. During 1993 - 1997 216 operations were performed. Between 1998 - 2002: 724 procedures, and during last year 345. Patients were treated during last year in ten surgical departments. The number of morbidly obese patients treated surgically in Poland is increasing, but it is still inadequate to meet the growing demand.