Routine anticoagulation for venous thromboembolism prevention following laparoscopic gastric bypass.

OBJECTIVE: To compare the rates of venous thromboembolism (VTE) by using routine postoperative enoxaparin versus early ambulation, SCDs, hydration, and selective prophylactic pharmacologic anticoagulation. METHODS: 1,692 patients undergoing laparoscopic gastric bypass from October 2001 to October 2008 were included and divided into 2 groups based on when they were operated upon. Group A (435 patients) received routine enoxaparin 12 hours after surgery. Group B (1,257 patients) received selective pharmacologic anticoagulation, in high-risk patients only. RESULTS: Mean operating time was 144±26 minutes (Group A) and 126±15 minutes (Group B). Mean length of stay was 2.3±1.5 days for Group A and 1.4±1.2 for Group B. Intraluminal bleeding occurred in 21 patients (4.8%) in Group A and 5 (0.9%) in Group B; none required intervention. Five pulmonary embolisms occurred in Group A (1.1%) and none in Group B. Seven patients in Group A (1.7%) and 6 (0.47%) in Group B had clinically evident DVT. Two non-VTE related deaths occurred in Group A. CONCLUSIONS: Adequate VTE prophylaxis is achieved using SCDs, early ambulation, emphasis on hydration, and shorter operating times. Bariatric surgery can be safely performed without pharmacologic VTE prophylaxis in all but the high-risk population. Fewer bleeding complications occur without the use of anticoagulants.

Hiatal hernia repair with mesh: a survey of SAGES members.

BACKGROUND: Primary repair of large hiatal hernia is associated with a high recurrence rate. The use of mesh may reduce this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. A survey of surgeon practice was undertaken to obtain a better understanding of the controversies surrounding this clinical problem. METHODS: A questionnaire on the technique and results of mesh hiatal herniorrhaphy was sent to 1,192 members of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES). RESULTS: There were 275 responses; 261 of these were analyzed. A total of 5,486 hiatal hernia repairs with mesh were reported; 77% and 23% were performed laparoscopically vs open, respectively. The most common indication for mesh usage was an increased size hiatal defect (46% of respondents). The most common mesh types were biomaterial (28%), polytetrafluoroethylene (25%), and polypropylene (21%). Suture anchorage was the most common fixation technique (56% of respondents). The findings showed a failure rate of 3%, a stricture rate of 0.2%, and an erosion rate of 0.3%. Biomaterial tended to be associated with failure, whereas nonabsorbable mesh tended to be associated with stricture and erosion. CONCLUSIONS: The use of mesh during hiatal hernia repair resulted in a reported recurrence rate which appeared to be lower than that obtained historically without mesh. No one mesh type was clearly superior in terms of avoiding failure and complication.

Laparoscopic Revision of Failed Bariatric Procedures.

BACKGROUND: The main indications for revision of bariatric surgery are inadequate weight loss, weight regain, or complications. The objective of revision is to restore the restrictive component and/or add a malabsorptive component. OBJECTIVES: To evaluate the effectiveness of revisional laparoscopic bariatric surgery for loss of weight and assess the risks and benefits associated with these technically demanding procedures. METHODS: Revision cases performed between 2001 and 2013 were identified and grouped according to the primary procedure and type of revision. A retrospective analysis was carried out for weight loss as well as perioperative morbidity and mortality. RESULTS: The total of 271 patients underwent revisional laparoscopic surgery during the study period and were categorized into four groups. Group 1 (n = 67) had an adjustable gastric band converted to gastric bypass (GBP). Group 2 (n = 128) had a dilated gastric pouch after GBP and underwent pouch reduction. Group 3 (n = 57) had a GBP and underwent pouch reduction and elongation of the biliopancreatic limb. Group 4 (n = 19) had a vertical banded gastroplasty converted to a GBP. The mean total body weight loss for Groups 1 to 4 was 35.3%, 22.9%, 39.4%, and 33.2%, respectively. The average operative times were 185, 75, 142, and 205 minutes; and the average hospitalization was 1.5, 1.0, 2.0, and 2.5 days, respectively. All cases were completed laparoscopically. Concomitant procedures were liver biopsy, cholecystectomy, partial gastrectomy, hiatal, ventral, and internal hernia repairs. Complication rates were 2.9%, 0%, 3.5%, and 5.2% for each of the groups and there were no mortalities. CONCLUSION: Results of revisional bariatric surgery vary depending on the original procedure and the reasons for revision. In particular, if the main reason for reoperation is inadequate weight loss, then the burden is to demonstrate a surgically correctable deficiency. Revisional procedures incorporating malabsorption result in greater weight loss than gastric restriction alone.

Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett's esophagus.

BACKGROUND: We present long-term follow-up data on patients with esophageal high-grade dysplasia and/or carcinoma in situ who were treated with laparoscopic transgastric esophageal mucosal resection (LTEMR). METHODS: Patient demographics, operative outcomes, and follow-up results were tabulated. RESULTS: LTEMR was performed in 11 patients (9 male, 2 female). The median age was 54 (44 to 75) years. The 30-day morbidity or mortality was zero. The median follow-up was 5.2 (2 to 12) years. Upper endoscopy was performed at 3, 6, and 12 month, and yearly thereafter. All patients regenerated squamous epithelium at 6 months. One patient developed a recurrence of Barrett's epithelium 2 years after resection. No recurrences of high-grade dysplasia or carcinoma were observed in any of the patients. Two patients developed an esophageal stricture; both were treated successfully with endoscopic balloon dilation and have suffered no further sequelae. CONCLUSIONS: LTEMR is safe and effective alternative method to treat patients with Barrett's esophagus with high-grade dysplasia.

A survey of dumping symptomatology after gastric bypass with or without lesser omental transection.

BACKGROUND: Lesser omental transection during gastric bypass for morbid obesity may be associated with postoperative dumping. A survey of postoperative symptoms was performed in patients undergoing laparoscopic Roux-en-Y gastric bypass with transection vs. preservation of the lesser omentum. METHODS: A written questionnaire on dumping symptoms was administered to patients 2 years after laparoscopic Roux-en-Y gastric bypass with or without transection of the lesser omentum. Statistical testing was performed to determine whether the rate of various symptoms was related to the transection of the lesser omentum. RESULTS: The patients without lesser omental transection had significantly less symptoms than the patients with transection for 11 out of the 17 symptoms that were queried (p < 0.05). Ingestion of sweets was associated with dumping symptoms more frequently in the group of transected patients, and this group also had a lower frequency of sweet eating (p < 0.05). CONCLUSION: This study demonstrated that transection of the lesser omentum during laparoscopic-gastric bypass was associated with more postoperative dumping symptoms compared to bypass with preservation of the lesser omentum. This association may be secondary to a partial vagotomy that may occur if the lesser omentum is transected during gastric bypass.