International survey on complications of religious fasting after metabolic and bariatric surgery.

Religious fasting in Ramadan the 9th month of the lunar year is one of five pillars in Islam and is practiced for a full month every year. There may be risks with fasting in patients with a history of metabolic/bariatric surgery (MBS). There is little published evidence on the possible complications during fasting and needs stronger recommendations and guidance to minimize them. An international survey was sent to surgeons to study the types of complications occurring during religious fasting in patients with history of MBS to evaluate the risk factors to manage and prepare more evidence-based recommendations. In total, 21 centers from 11 countries participated in this survey and reported a total of 132 patients with complications occurring during religious fasting after MBS. The mean age of patients with complications was 36.65 ± 3.48 years and mean BMI was 43.12 ± 6.86 kg/m2. Mean timing of complication occurring during fasting after MBS was 14.18 months. The most common complications were upper GI (gastrointestinal) symptoms including [gastroesophageal reflux disease (GERD), abdominal pain, and dyspepsia], marginal ulcers and dumping syndrome in 24% (32/132), 8.3% (11/132) and 23% (31/132) patients respectively. Surgical management was necessary in 4.5% of patients presenting with complications (6/132) patients due to perforated marginal or peptic ulcer in Single Anastomosis Duodenoileostomy with Sleeve gastrectomy (SADI-S), one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG), obstruction at Jejunojenostomy after Roux-en-Y gastric bypass (RYGB) (1/6) and acute cholecystitis (1/6). Patients after MBS should be advised about the risks while fasting including abdominal pain, dehydration, and peptic ulcer disease exacerbation, and a thorough review of their medications is warranted to minimize complications.

Severity of post-Roux-en-Y gastric bypass dumping syndrome and weight loss outcomes: is there any correlation?

PURPOSE: The present research was conducted to evaluate the effect of the severity of dumping syndrome (DS) on weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in patients with class III obesity. METHODS: The present retrospective cohort study used the dumping symptom rating scale (DSRS) to evaluate the severity of DS and its correlation with weight loss outcomes in 207 patients 1 year after their RYGB. The patients were assigned to group A with mild-to-moderate DS or group B with severe DS. RESULTS: The mean age of the patients was 42.18 ± 10.46 years and their mean preoperative BMI 42.74 ± 5.59 kg/m2. The total weight loss percentage (%TWL) in group B was insignificantly higher than that in group A, but besides that was not significantly different in the two groups. CONCLUSION: The present findings suggested insignificant relationships between the presence and severity of DS after RYGB and adequate postoperative weight loss.

Association of Hypercholesterolemia With Gastric Intestinal Metaplasia, Findings After Sleeve Gastrectomy Pathology Review.

BACKGROUND: We evaluated the relationship between comorbidities associated with obesity, body mass index (BMI), and development of intestinal metaplasia (IM) after vertical sleeve gastrectomy (VSG). MATERIALS AND METHODS: All VSG specimens performed at an academic center between 2011 and 2018 were reviewed. All specimens underwent histopathologic assessment, while those with findings suspicious for IM underwent additional immunohistochemical work up. Baseline patient characteristics and demographic data were obtained from Iran National Obesity Surgery Database by retrospective review. RESULTS: A total of 862 adult individuals underwent VSG during the study period and specimens were histopathologically examined. All patients had preoperative upper endoscopy. The most common histopathologic diagnosis was miscellaneous findings (57.8%) followed by no pathologic finding (36.7%). The minority of patients (5.5%) had IM. Although 40.5% of patients had positive Helicobacter pylori infection preoperatively, just 13.8% had still positive infection postoperatively. A significant association was found between IM and hypercholesterolemia (odds ratio: 1.95; 95% confidence interval: 1.1, 3.5). CONCLUSION: This study found a correlation between histopathologic changes in patients with IM and hypercholesterolemia. Prospective research studies are recommended to further examine this correlation.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus.

BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Revision procedures after initial Roux-en-Y gastric bypass, treatment of weight regain: a systematic review and meta-analysis.

Morbid obesity is a global chronic disease, and bariatric procedures have been approved as the best method to control obesity. Roux-en-Y gastric bypass is one of the most common bariatric surgeries in the world and has become the gold standard procedure for many years. However, some patients experience weight regain or weight loss failure after the initial bypass surgery and require revisional or conversional interventions. International databases including PubMed, International Scientific Indexing (ISI), and Scopus were considered for a systematic search of articles that were published by 5th of May 2020. Forty-one published studies, which reported revision procedure on 1403 patients, were selected and analyzed for this review. The selected studies were categorized into six groups of revision procedures, including laparoscopic pouch resizing and/or revision of gastro-jejunal anastomosis (GJA), adjustable or non-adjustable gastric band over pouch ± pouch/GJA resizing, endoscopic revision of gastric GJA ± pouch, distal Roux-en-Y gastric bypass (DRGB), biliopancreatic diversion with duodenal switch (BPD-DS) or single anastomosis duodeno-ileal bypass with gastric sleeve (SADI-S), DRGB + Band or pouch/GJA resizing. Revision procedures result in more weight loss after the initial weight loss procedures. In the one-year follow-up, DRGB by itself with standardized mean difference (SMD) of - 1.24 presented a greater decrease in body mass index (BMI). DRGB plus band or pouch/GJA resizing, BPD-DS or SADI, adjustable or non-adjustable gastric banding over pouch ± pouch/GJA resizing, endoscopic pouch and/or GJA revision and laparoscopic pouch or/and GJA resizing revealed a lower decrease in BMI in order, respectively. In the three-year follow-up, BPD-DS or SADI-S method with SMD of - 1.40 presented the highest decrease in BMI. In follow, DRGB alone, adjustable or non-adjustable gastric banding over gastric pouch ± pouch / GJA resizing, DRGB + Band or gastric pouch/GJA resizing, laparoscopic pouch and/or GJA resizing and endoscopic revision of pouch and/or GJA revealed less reduction in BMI, respectively. In the five-year follow-up, DRGB alone procedures with SMD of - 2.17 presented the greatest reduction in BMI. Subsequently, BPD-DS or SADI-S, laparoscopic pouch and/or GJA size revision, and endoscopic revision of GJA/pouch revealed less overall decrease in BMI in order. All methods of revision procedures after the initial RYGB have been effective in the resolution of weight regain. However, based on the findings in this systematic review, it seems DRGB or BPD-DS/SADI-S is the most effective procedure in the long-term follow-up outcome. More studies with a higher number of patients and even longer follow-ups will be required to obtain more accurate data and outcome.

One-stage robotically assisted laparoscopic biliopancreatic diversion with duodenal switch: analysis of 179 patients.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) has been reported to be the most effective procedure for weight loss and minimizing postoperative weight regain. However, because of its technical complexity and concerns for higher operative and metabolic complications, it has not obtained widespread acceptance among patients or bariatric surgeons. Nevertheless, the use of robotic systems has been increasing because of its ability to overcome technical challenges, such as torque, freedom of movement, and precision. The objective of this study was to review the efficacy and safety of robotic assistance in laparoscopic BPD-DS. METHODS: A prospectively maintained database of patients who underwent robotic-assisted laparoscopic BPD-DS between 2008 and 2013 was reviewed retrospectively. RESULTS: A total of 179 consecutive patients (137 female and 42 male) were included in the study. The mean age was 44 years (20-72 yr). Mean body mass index (BMI) was 50.3 kg/m(2) (35-78.8 kg/m(2)), and the number of preoperative co-morbidities was 6.6 (2-14). Mean operative time for a typical BPD-DS with appendectomy was 249 minutes (162-413 min), which increased to 278 minutes (193-463 min) in adhesiolysis associated cases and increased to 272 minutes (186-431 min) if additional procedures, such as hiatal hernia repair, cholecystectomy, or Meckel's diverticulum resection, were included. All procedures were completed as a single-stage operation. There were no major intraoperative complications. Two patients had unexpected returns to the operating room during the same admission: one for an endoscopic release of an inadvertently sutured nasogastric tube and the other for port site infection. Median hospital stay was 2.7 days (1-13). Two patients had significantly longer stays for carpal tunnel syndrome exacerbation (9 d) and port site infection (13 d). Postoperatively, the median excess weight loss at 1, 3, 6, 9, 12, 18, 24, and 36 months with follow-up of 71% of patients at 1 year, 45% of patients at 2 years, and 15% of patients at 5 years, was 19%, 35.9%, 53.1%, 65.6%, 74.6%, 79.9%, and 75.8%, respectively. Diabetes, hypertension, and hyperlipidemia went into remission 95.5%, 92.1%, and 92% of the time, respectively. No mortality occurred. CONCLUSIONS: Robotically assisted duodenoileal anastomosis during laparoscopic BPD-DS is a feasible, well-tolerated, and effective alternative to assist in the technically challenging part of the operation.

Traumatic arteriovenous fistula after kickboxing injury: a case report and review of the literature.

INTRODUCTION: A traumatic arteriovenous fistula (AVF) after repetitive blunt trauma has not been described previously. In a 34-year-old male, the first reported case of such an injury after repetitive blunt trauma is described. CASE PRESENTATION: A 34-year-old gentleman presented with a non-healing ulcer near his medial malleolus. A bone scan was performed and then treated for presumed osteomyelitis. An arteriogram confirmed an AVF, and coil embolization was performed with complete occlusion of the AVF. Subsequently, the ulcer healed rapidly with no complication. Along with the cause of AVF, this case is notable for symptom presentation. CONCLUSIONS: Arteriovenous fistula after blunt trauma can present as a non-healing venous stasis ulcer, which could be treated non-invasively.

Is laparoscopic single-stage biliopancreatic diversion with duodenal switch safe in super morbidly obese patients?

BACKGROUND: It has been hypothesized that the morbidity and mortality of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) are likely to increase with increasing body mass index (BMI), especially with BMI>50 kg/m(2). Therefore, a 2-stage approach to this procedure has been advocated in super morbidly obese patients. The authors hypothesized that a BMI ≥ 50 kg/m(2) does not significantly influence the morbidity and mortality perioperatively associated with this procedure. METHODS: A retrospective analysis of all patients who underwent laparoscopic BPD-DS between January 2009 and September 2011 was performed. The patients were divided into 2 groups: patients with BMI<50 kg/m(2) and those with BMI>50 kg/m(2). Patient characteristics, perioperative variables, 30-day outcomes, and complications were analyzed and compared. RESULTS: A total of 226 patients underwent laparoscopic BPD-DS. Mean patient age was 44.9 years (range: 20-72 yr). Male to female ratio was 59 to 170 patients (75% versus 25%), respectively. Mean BMI was 50.2 kg/m(2) (range: 37.2-68.8 kg/m(2)). A total of 127 patients had a BMI<50 kg/m(2) (Group 1), and 99 patients had a BMI ≥ 50 kg/m(2) (Group 2). The length of procedure in Groups 1 and 2 was 296 minutes and 287 minutes, respectively (P = .25). The rate of conversion to open BPD-DS was 1.5% in Group 1 and 3% in Group 2 (P = .65). Two leaks occurred in Group 1; no patient in Group 2 developed this complication. One patient in Group 2 developed pulmonary embolism. The rates of all other complications resulting in a longer length of stay were 11% in Group 1 and 8% in Group 2 (P = .50). The 30-day reoperation rate was 3% in Group 1 and 1% in Group 2 (P = .39). The mean length of stay was 3.97 days for Group 1 and 3.67 days for Group 2 (P = .34). No mortality occurred in this series. CONCLUSION: In the present study, BMI ≥ 50 kg/m(2) did not increase intraoperative or postoperative complications at 30 days after laparoscopic PBD-DS. No significant differences were noted between patients with BMI ≥ 50 kg/m(2) and patients with BMI<50 kg/m(2). A single-stage laparoscopic BPD-DS procedure can be safely offered to the super morbidly obese patients.

Venous thromboembolism after laparoscopic biliopancreatic diversion with duodenal switch: analysis of 362 patients.

BACKGROUND: Venous thromboembolism (VTE), which manifests as deep venous thrombosis (DVT) or pulmonary embolism (PE), is relatively uncommon after weight loss procedures but has the strong potential to affect patient morbidity and mortality. This type of complication has been studied extensively in more common weight loss procedures, such as Roux-en-Y gastric bypass (RYGB). VTE has not been studied after biliopancreatic diversion with duodenal switch (BPD-DS), a bariatric procedure performed mainly for super morbidly obese patients, who are inherently associated with a higher incidence of co-morbidity. The objective of this study was to review VTE prevalence and identify risk factors associated with the postoperative occurrence of VTE in a collected data set of patients after laparoscopic BPD-DS. METHODS: The database of all patients who underwent laparoscopic BPD-DS between 2006 and 2012 was reviewed. Preoperative clinical information, which included history of VTE, inferior vena cava (IVC) filter placement, operative variables, and postoperative course, were reviewed. All VTE related events that occurred within 90 days postoperatively were collected and analyzed. RESULTS: Of 362 patients who underwent laparoscopic BPD-DS during the study period, 12 (3.3%) experienced a VTE complication. Eight (2.2%) patients presented with DVT; 4 (1.1%) patients presented with PE. VTE complications were more common in females than males (83.3% versus 16.6%, respectively). Age, body mass index (BMI), and time interval between preoperative and postoperative doses of heparin for DVT prophylaxis did not influence the occurrence of VTE complications. However, operative time (P = .02) and length of hospital stay (P = .0005) were identified as risk factors associated with postoperative VTE complications. No related mortality occurred in this study. CONCLUSION: The prevalence of VTE after BPD-DS is relatively low and comparable to other weight loss procedures. Overall risk of postoperative VTE after laparoscopic BPD-DS appears to be associated with the length of operation and hospital stay.

Conversion of laparoscopic colon resection does not affect survival in colon cancer.

BACKGROUND: Laparoscopic and open resections of colon cancer are considered oncologically equivalent treatment methods. Conversion of laparoscopic procedures, however, was associated with decreased survival in colon cancer patients in the only prior study examining this question. We conducted this study to evaluate the effect of conversion on survival. METHODS: A series of consecutive patients treated with laparoscopic resection of colorectal cancer (n = 174) in the period 1998-2003 was evaluated retrospectively. Median follow-up was 51 months with a minimum of 3 years. RESULTS: There was no statistically significant difference in all-cause mortality between laparoscopically completed and converted groups (22/143, 15.4% versus 8/31, 25.8%; OR 1.9, p = 0.164). Kaplan-Meier survival analysis did not show any survival difference between the two groups (p = 0.266). CONCLUSIONS: The results of our study suggest there is no survival difference in patients requiring conversion of laparoscopic resection indicated for colorectal cancer. Further examination of this question is warranted to determine whether laparoscopic resection of colorectal cancer should be offered to all patients, including those at high risk for conversion.

Outcomes in patients treated by laparoscopic resection of rectal carcinoma after neoadjuvant therapy for rectal cancer.

OBJECTIVE: We analyzed the effect of neoadjuvant chemo radiation on feasibility and outcomes in rectal cancer patients undergoing laparoscopic resection of the rectum. METHODS: This was a retrospective analysis of a consecutive series of laparoscopic resections for rectal cancer from 1998 to 2004 (N=60). RESULTS: Eight patients received preoperative chemoradiation therapy (neoadjuvant group) for rectal cancer and 52 patients did not (primary surgical group). The conversion rate was higher in the neoadjuvant group, but this did not reach statistical significance (3/8, 37% in the neoadjuvant group vs. 7/52, 13% in the primary surgical group, P=0.12). Operative time was longer in the neoadjuvant group (170+/-60 vs 228+/-70 min, P=0.03). Complication rates (3/52, 5.7% in the primary surgical vs. 0% in the neoadjuvant group, P=1.0), and a median number of resected lymph nodes (14.5 in the primary surgical vs. 16.0 in the neoadjuvant group, P=0.81) were similar between groups. CONCLUSION: Laparoscopic resection of rectal cancer in patients after preoperative chemoradiation treatment seems to be associated with a higher conversion rate and a longer duration of surgery. No change in mortality and morbidity was detected. We encourage further investigation of laparoscopic rectal surgery for treatment of rectal cancer.

Late pancreaticojejunostomy stent migration and hepatic abscess after Whipple procedure.

A previously unreported late complication of a transanastomotic stent across a pancreaticotojejunostomy is described. The stent migrated distally into the jejunal lumen, through the biliary anastomis into the bile duct and proximally into the liver where it served as a nidus for infection with abscess formation. A percutaneous transhepatic interventional radiologic approach both drained the abscess and pushed the stent out of the liver and biliary tree and into the bowel, with complete recovery. The decision by the surgeon to use a stent in these patients is discussed, and the complications associated with stenting a pancreaticojejunostomy are reviewed.