Extracorporeal Membrane Oxygenation Rescue for Severe Aspiration Pneumonitis in Two Patients after Roux-en-y Gastric Bypass Procedure.

Roux-en-y gastric bypass (RYGB) is one of the most common weight loss surgical procedures performed in the United States. Early post-operative small bowel obstruction is a rare but potentially morbid, complication of RYGB. We report two patients who underwent RYGB and required subsequent treatment for a post-operative small bowel obstruction. Their post-operative course was complicated by severe aspiration pneumonitis leading to hypoxemic respiratory failure requiring rescue with femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO). Both patients were successfully extubated, weaned off V-V ECMO support, and discharged to home. These cases highlight the potential role of V-V ECMO for patients who have undergone RYGB and develop severe aspiration pneumonitis. They also highlight the need for cautionary use of gastrografin in RYGB patients. Early engagement of a multidisciplinary team experienced with adult ECMO is vital for favorable patient outcomes.

Routine preoperative endoscopy in patients undergoing bariatric surgery.

BACKGROUND: The role of routine preoperative endoscopy before primary weight loss surgery remains controversial. OBJECTIVE: We reviewed our experience to determine the frequency of abnormal findings in patients undergoing routine preoperative endoscopy before bariatric surgery. SETTING: A tertiary level, academic-affiliated bariatric surgery practice. METHODS: A retrospective chart review was performed between July 2014 and June 2016 of patients undergoing routine preoperative endoscopy before primary bariatric surgery. Variables evaluated included preendoscopy symptoms, planned bariatric surgical procedure, abnormal findings on endoscopy, and changes in planned bariatric surgical procedure after endoscopy. RESULTS: A total of 631 patients met inclusion criteria. Of patients, 72% (457) were female. The median age was 44 (interquartile range 36-55). The median body mass index was 46 (interquartile range 42-51). Most patients had no preendoscopy clinical symptoms (61.3%). The most frequent abnormal findings included esophagitis (26.5%), hiatal hernia (27.1%), gastric ulcer (4.9%), and biopsy-proven Barrett's esophagus (4.6%). Although patients with preoperative symptoms were more likely to have abnormal findings on endoscopy, there were no significant differences in rates of Barrett's esophagus in patients with (5.3%) or without (4.1%) symptoms. Of the total cohort, 18.4% had a change in their planned operation after endoscopy results. CONCLUSION: The findings in our large series suggest selective screening in symptomatic patients only may lead to failure of discovery of foregut pathology that should prompt consideration for changes in the planned bariatric surgical procedure. Further study is necessary to see if our findings have broad applicability.

Decreased access to bariatric care: an analysis of referral practices to bariatric specialists.

BACKGROUND: Substantial evidence reveals tolerability and co-morbid disease resolution after bariatric surgery; however, few physicians refer morbidly obese patients for bariatric consultation. OBJECTIVE: To evaluate morbidly obese patient access to bariatric surgical consultation. SETTING: A multidisciplinary, private, bariatric center of excellence. METHODS: Patient surveyed in person regarding preconsultation co-morbidities, physician discussion and support for bariatric surgery, and physician referral practices. RESULTS: The patients' (n = 388) co-morbid profile was 27.0% diabetes, 54.1% hypertension, 30.1% hyperlipidemia, and 37.1% obstructive sleep apnea. It was reported that 71.1% of patients stated that their primary care physician did not initiate a discussion about bariatric surgery. Among this group, 59.7% of patients initiated a conversation about bariatric surgery, with 80.6% of physicians supporting the decision and 18.4% referring to a bariatric practice. Overall referring specialty profile was 14.4% primary care, 4.4% cardiology, and 3.6% endocrinology. Diabetes and obstructive sleep apnea were more likely to prompt a referral (P = .008 and P = .014, respectively). CONCLUSION: Most primary care and subspecialists do not discuss bariatric surgical options, resulting in decreased access to bariatric care. The main barrier to referral is noncommunication by the primary care physician or subspecialist, despite the vast majority of physicians having positive attitudes about bariatric surgery. Co-morbidities of diabetes and obstructive sleep apnea are more likely to prompt a referral. Primary care physicians are most likely to refer, while endocrinologists are least likely. Improved familiarity with nationally recognized obesity management algorithms could contribute to improved referral rates.