Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.

Bariatric surgery continues to be the most reliable treatment for the disease of obesity. Despite excellent results, some patients experience weight recurrence with or without concomitant recurrence of co-morbidities. There is currently no standard definition for clinically significant weight recurrence after bariatric surgery so that patients and clinicians have a platform from which to plan treatment. The Post-Operative Weight Recurrence (POWER) Task Force was formed by the American Society for Metabolic and Bariatric Surgery to address this aspect of the disease of obesity. This article reviews the literature of existing definitions for weight recurrence and their limitations. Furthermore, the term weight recurrence is introduced to replace weight regain or recidivism, and the term nonresponder is introduced to replace inadequate weight loss after surgery.

A 5-Year History of Laparoscopic Gastric Band Removals: an Analysis of Complications and Associated Comorbidities.

OBJECTIVE: This study was undertaken to examine the factors contributing to laparoscopic adjustable gastric band (LAGB) removals among adults > 18 years of age. We hypothesized that female patients with multiple comorbidities would have increased removals. DESIGN: This retrospective exploratory study uses internal records and standard statistical methods of analysis. RESULTS: Eighty-five bands were removed (11.8% males, 88.2% females). The average BMI was 40.7 (n = 83). 2.4% of patients had removals between 0 and 12 months, 18.8% between 39 and 51 months, and 35.3% between 39 and 64 months. 8.2% of treatment times were unknown. The average treatment time was 67.9 months. 48.2% of patients had ≥ 2 comorbidities, GERD (44.2%) being the most frequent. 49.4% of patients reported dysphagia as the reason for band removal. 22.4% of removals were associated with band failures, none with port complications. The reason for band removal was unknown in 21.2% of patients. 67.1%, 32.9%, and 23.5% attended 30-, 60-, and 90-day follow-up appointments, respectively. Weight post-band removal surgery at 30, 60, and 90 days was noted to be - 0.4%., 0.9%, and 0.4%, respectively. CONCLUSION: This study supports current literature suggesting LAGB may not be an effective long-term surgical intervention for obesity. Patients with > 2 comorbidities had increased rates of removal. Dysphagia was noted to be the primary reason cited for LAGB removal. Postoperative follow-up was found to be a significant challenge for LAGB removal patients. Further study is warranted to explore if these poor follow-up rates should be considered when risk stratifying LAGB patients for revisional surgery.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018.

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

Myasthenia gravis improvement after laparoscopic Roux-en-Y gastric bypass.

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m2, and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.

Gastric perforation secondary to ingestion of a sharp foreign body.

Foreign body ingestions are commonly seen by pediatricians and emergency room personnel. The majority of foreign bodies transit through the gastrointestinal system without any complications. Perforations are uncommon and usually involve peritonitis. We present a case of gastric perforation secondary to ingestion of a sharp metallic pin. Our patient did not demonstrate any of the classic findings described in the literature. His complaints, physical examination, and radiological findings all pointed to acalculous cholecystitis or biliary dyskinesia as the source of pain. Laparoscopy, however, provided the definitive diagnosis. Gastroduodenal perforation secondary to foreign body ingestion should be included in the differential diagnosis of these atypical cases of abdominal pain, especially if such history can be elicited from the patient.

Renal failure, glomerulonephritis and morbid obesity: improvement after rapid weight loss following laparoscopic gastric bypass.

There is experimental evidence but very few human studies that suggest a role for obesity in the formation and progression of some glomerular lesions. We report the case of a morbidly obese male with hematuria and proteinuria that was subsequently diagnosed with renal failure which required dialysis. Histological findings of the renal biopsy performed during a laparoscopic gastric bypass are presented. His renal failure resolved with the weight loss.

Laparoscopic removal of gastric band after early gastric erosion: case report and review of the literature.

Laparoscopic gastric banding is a popular method for treating morbid obesity. One of the most serious complications is band erosion into the gastric lumen. We present the case of a patient who underwent gastric banding and presented with symptoms of gastrointestinal reflux and mild-to-moderate hypertension, fever, and pain. UGI revealed stomach wall erosion and partial migration of the band into the gastric lumen. The band was laparoscopically removed without any further complications. Migration after laparoscopic gastric banding must be immediately addressed to prevent infection. Close monitoring of the band location during adjustments as well as a high index of suspicion is necessary.

Routine abdominal drains after laparoscopic Roux-en-Y gastric bypass: a retrospective review of 593 patients.

BACKGROUND: The authors reviewed the benefits of routine placement of closed drains in the peritoneal cavity following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of the study was to determine whether routine closed abdominal drainage provides diagnostic and therapeutic advantages in the presence of complications such as bleeding and leaks. MATERIALS AND METHODS: The medical records of 593 consecutive patients who had undergone LRYGBP from July 2001 through May 2003 were retrospectively reviewed. In all cases, antecolic antegastric LRYGBP was performed. Two 19-Fr Blake closed suction drains were left in place, one at the gastrojejunostomy and the other at the jejunojejunostomy. The incidence of bleeding and leaks was reviewed, and the utility of the drains relative to diagnosis and management was evaluated. RESULTS: Bleeding presented in 24 patients (4.4%); in 8, the diagnosis was based on increased sanguinous output from the drain and decreased hematocrit. None of the patients with intraabdominal bleeding required reoperation. Of the 10 patients (1.68%) who presented with leaks, the diagnosis was made within 48 hours postoperatively in 5 patients (50%), based on the characteristics of the drain output. Nonoperative management with drainage and total parenteral nutrition was accomplished in 5 (50%) of the 10 patients with leaks. There was no mortality in the series. CONCLUSION: The routine use of abdominal drains after LRYGBP appears to be beneficial. Drains allowed early diagnosis of complications and in most cases, the successful treatment of leaks. When bleeding is suspected or documented, appropriate volume replacement therapy is mandatory to maintain adequate hemodynamic parameters. Drain output may orient the surgeon to take preventive measures such as discontinuing anticoagulation and early fluid resuscitation. In this series, in most cases the bleeding spontaneously stopped and no further surgical management was required.