Effect of long-term proton pump inhibitor therapy on hemoglobin and serum iron levels after sleeve gastrectomy.

BACKGROUND: Iron deficiency anemia and iron deficiency are commonly seen after bariatric surgery. Gastroesophageal reflux disease is commonly associated with sleeve resections and warrants postoperative acid reducing therapy. OBJECTIVE: To analyze the impact of long-term proton pump inhibitors on iron deficiency or iron deficiency anemia in laparoscopic sleeve gastrectomy (LSG) patients. SETTING: University hospital, USA. METHODS: A single-institution case control study included 2 groups of bariatric patients who underwent LSG. Patient characteristics such as age, sex, American Society of Anesthesiologists risk, body mass index, nutritional status, and co-morbidities were comparable. Postoperative follow-up was scheduled at 1-week, and 1-, 3-, 6-, and 12-month durations. All received standard postoperative iron, multivitamin therapy, and nutritional screening and evaluation. All patients were placed on postoperative proton pump inhibitors (PPI) therapy for at least 3 months. At third postoperative visit, anemia indicators were assessed by serum iron concentration, total iron binding capacity, transferrin saturation, red blood cell count, hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin concentration. Postoperative hemoglobin and serum iron levels were compared between those patients still taking PPIs to those not taking PPIs at 12 months. RESULTS: A total of 287 patients underwent LSG from January 2016 to December 2017, 203 were included and 84 patients were excluded. Patients taking long-term PPIs (>12 mo, n = 85) were compared with those not taking PPIs (n = 118) and outcomes were respectively as follows: mean pre- and postoperative hemoglobin levels (in g/DL) were 13.2 and 10.7, and 13.3 and 13.7; mean postoperative serum iron levels (in µg/DL) were 41.7 and 88.7. Results were computed using paired t test and odds ratio that showed iron deficiency anemia in 12.9% (11/85) in PPI group compared with 4.23% (5/118) in the non-PPI group (odds ratio of 3.3, 95% confidence interval [1.21-10], and P = .03). Iron deficiency was seen in 22.3% (19/85) in the PPI group and 11% (13/118) in the non-PPI group (odds ratio of 2.3, 95% confidence interval [1.07-5.02] and P = .031). CONCLUSIONS: Our study indicates that PPIs can increase the severity of iron deficiency and iron deficiency anemia in patients who underwent LSG. Aggressive surveillance is needed in those taking long-term PPIs after LSG. It is encouraged to further analyze these findings in a larger randomized study model design.

An unusual case of perisplenic small bowel volvulus after laparoscopic Roux En Y gastric bypass.

Internal hernias (IH) are one of the dreadful complications of laparoscopic Roux En Y gastric bypass (LGBP). Commonly reported internal hernias (IH) following Roux En Y gastric bypass (LGBP) in the literature are meso-colic, meso jejunal and Peterson's space hernias. These patients may not have any definitive symptoms. Findings are often missed on radiological studies and a high index of clinical suspicion is often necessary. If in doubt, a timely diagnostic laparoscopy is critical to decrease morbidity and mortality in these patients. We present a very unusual case of peri-splenic small bowel herniation with volvulus following LGBP with indeterminate radiological findings. Our case emphasizes that early laparoscopy is both diagnostic and therapeutic for desirable clinical outcomes.

Infrared illumination during thoracoscopic excision of mediastinal bronchogenic cysts.

Bronchogenic cysts are congenital abnormalities that occur due to abnormal development of the ventral foregut. Most share a common wall with the esophagus. Excision is indicated to prevent complications such as mass effect or infection. Thoracoscopic resection has been previously described. Injury to the adjacent esophagus is a potential complication due to its close proximity, and placement of an esophageal bougie is often used to help identify the esophagus. We describe a technique utilizing the InfraVision Esophageal Kit (Stryker Endoscopy, San Jose, California) to assist in the illumination of the esophagus during dissection of mediastinal bronchogenic cysts in 3 children. The system consists of an infrared light-emitting probe and an infraredsensing endoscopic camera. The probe is easily placed prior to surgery, and allows for easy identification of the esophagus. It also clarifies the dissection plane between the cyst and the esophagus. This technique facilitates dissection of mediastinal cysts and helps avoid injury to the esophagus. It was found to be safe and effective in 3 children. The system may be applicable to other esophageal operations such as Nissen fundoplication or Heller myotomy.