Single anastomosis duodenal switch versus Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m2: a multi-centered comparative analysis.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has consistently demonstrated excellent weight loss and comorbidity resolution. However, outcomes vary based on patient's BMI. Single anastomosis duodeno-ileostomy with sleeve (SADI-S) is a novel procedure with promising short-term results. The long-term outcomes of SADI-S in patients with BMI ≥ 50 kg/m2 are not well described. We aim to compare the safety and efficacy of SADI-S with RYGB in this patient population. METHODS: We performed a multicenter retrospective study of patients with a BMI ≥ 50 kg/m2 who underwent RYGB or SADI-S between 2008 and 2023. Patient demographics, peri- and post-operative characteristics were collected. Complication rates were reported at 6, 12, 24, and 60 months postoperatively. A multivariate linear regression was used to evaluate and compare weight loss outcomes between both procedures. RESULTS: A total of 968 patients (343 RYGB and 625 SADI-S; 68.3% female, age 42.9 ± 12.1 years; BMI 57.3 ± 6.7 kg/m2) with a mean follow-up of 3.6 ± 3.6 years were included. Patients who underwent RYGB were older, more likely to be female, and have a higher rate of sleep apnea (p < 0.001), hypertension (p = 0.015), dyslipidemia (p < 0.001), and type 2 diabetes (p = 0.016) at baseline. The rate of bariatric surgery-specific complications was lower after SADI-S compared to RYGB. We reported no bariatric surgery related deaths after 1 year following both procedures. SADI-S demonstrated statistically higher and sustained weight loss at each time interval compared to RYGB (p < 0.001) even after controlling for multiple confounders. Lastly, the rate of surgical non-responders was lower in the SADI-S cohort. CONCLUSIONS: In our cohort, SADI-S was associated with higher and sustained weight-loss results compared to RYGB. Comorbidity resolution was also higher after SADI-S. Both procedures demonstrate a similar safety profile. Further studies are required to validate the long-term safety of SADI-S compared to other bariatric procedures.

Reflux After Sleeve Gastrectomy: Safety and Effectiveness of Laparoscopic Ligamentum Teres Cardiopexy, a Single-Center Experience.

BACKGROUND: Obesity is a well-known risk factor for gastroesophageal reflux disease (GERD). Even though symptoms may be mitigated or resolved with the weight loss caused by sleeve gastrectomy (SG), it may be associated with higher incidences of postoperative GERD. Ligamentum teres cardiopexy (LTC) is an alternative to Roux-en-Y gastric bypass, the gold standard treatment for GERD. METHODS: This study was a retrospective single-center chart review, all patients in this cohort underwent LTC to treat refractory GERD at our institution. The option for LTC was presented after patients' refusal to undergo RYGB conversion. We collected baseline characteristics, standard demographics, pre-operative tests and imaging, and SG information, as well as intraoperative and perioperative data regarding LTC, and postoperative complications. RESULTS: Our cohort included 29 patients; most were Caucasian (44.8%) females (86.2%). The mean weight and BMI before LTC were 216.5 ± 39.3 lb and 36.1 ± 5.4 kg/m2, respectively. Mean total body-weight loss (TBWL) at 12 and 24 months were 28.7% ± 9.5% and 28.4% ± 12.4%, respectively. The mean interval between the index bariatric surgery and LTC was 59.9 ± 34.9 months, mean operative time was 67 ± 18.2 min, and median length of stay (LOS) was 1 day (IQR = 1-2 days). Twelve patients (57.1%) were able to discontinue antisecretory medications, while 9 (42.9%) still required them to remain asymptomatic. Mortality and reoperation rates were 0% and the incidence of complication was 19.4% (n = 6). CONCLUSIONS: LTC is a safe and effective surgical alternative to treat refractory GERD symptoms after SG.

Management of Malnutrition and Hepatic Impairment After Duodenal Switch.

BACKGROUND: Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications. METHODS: A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study. RESULTS: Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively. CONCLUSIONS: While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates.

Comparative multicenter analysis of sleeve gastrectomy, gastric bypass, and duodenal switch in patients with BMI ≥70kg/m2: a 2-year follow-up.

Patients undergoing metabolic and bariatric surgery (MBS) with body mass index (BMI) ≥ 70 kg/m2 are considered a high-risk group. There is limited literature to guide surgeons on the perioperative safety as well as the different procedural outcomes of MBS in this cohort. Our aim is to compare the safety profiles, early- and medium-term outcomes of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients with BMI ≥ 70 kg/m2. A total of 156 patients with BMI ≥ 70kg/m2 underwent MBS (SG = 40, RYGB = 40, and DS = 76). Mean baseline BMI was 75.5 kg/m2. Total weight loss (%TWL) at 24 months was highest in the DS group compared to RYGB (40.6% versus 33.8%, P value = .03) and SG (40.6% versus 28.5%, P value = .006). There was no significant difference in %TWL between RYGB and SG (33.8% versus 28.5%, P value = .20). The 30-day complication rates were similar [SG (7.5%), RYGB (10%), and DS (9.2%) (P value = 1.0)]. There was one reported leak (DS). The 30-day mortality was zero. MBS is safe and effective in patients with BMI ≥ 70 kg/m2. All procedures had comparable safety profiles and complication rates. While DS achieved the highest %TWL at 24 months, similar comorbidity resolution rates among the procedures attenuate its clinical significance.

Marginal Ulcer and Dumping Syndrome in Patients after Duodenal Switch: A Multi-Centered Study.

BACKGROUND: The current design of biliopancreatic diversion with duodenal switch (BPD/DS) and single anastomosis duodenal-ileal bypass with sleeve (SADI-S) emphasizes the importance of the pylorus' preservation to reduce the incidence of marginal ulcer (MU) and dumping. However, no institutional studies have yet reported data on their prevalence. We aimed to assess the incidence of MU and dumping after duodenal switch (DS) and identify the associative factors. METHODS: A multi-center review of patients who underwent BPD/DS or SADI-S between 2008 and 2022. Baseline demographics, symptoms, and management of both complications were collected. Fisher's exact test was used for categorical variables and the independent t-test for continuous variables. RESULTS: A total of 919 patients were included (74.6% female; age 42.5 years; BMI 54.6 kg/m2) with mean follow-up of 31.5 months. Eight patients (0.9%) developed MU and seven (0.8%) had dumping. Patients who developed MU were more likely to be using non-steroidal anti-inflammatory drugs (NSAID) (p = 0.006) and have a longer operation time (p = 0.047). Primary versus revisional surgery, and BDP/DS versus SADI-S were not associated with MU or dumping. CONCLUSIONS: The incidences of MU and dumping after DS were low. NSAID use and a longer operation time were associated with an increased risk of MU, whereas dumping was attributed to poor dietary habits.

Analysis of the Impact of the Learning Curve on the Safety Outcome of the Totally Robotic-Assisted Biliopancreatic Diversion with Duodenal Switch: a Single-Institution Observational Study.

INTRODUCTION: Totally robotic-assisted biliopancreatic diversion with duodenal switch (BPD/DS) learning curve has been described to be longer at approximately 50 cases, at which point operative time and complications rate decrease and tend to stabilize. This study aimed to form an analysis of the impact of the learning curve on the safety outcomes of the totally robotic-assisted BPD/DS. METHODS: A retrospective review of patients who underwent primary totally robotic-assisted BPD/DS by one of our certified bariatric and metabolic surgeon member of our institution was performed. The patients were classified into two groups, the learning stage group (first 50 cases) and the mastery stage group. Differences in operative time in minutes and postoperative outcomes were analyzed. RESULTS: Two hundred seventy-six patients were included. The operative time and the postoperative length of stay were significantly higher in the learning stage group (173.8 ± 35.8 min vs. 139.2 ± 30.2 min, p= 0.0001; 3.4 ± 1.4 days vs. 2.6 ± 0.9 days, p= 0.0002). The overall leakage rate was significantly higher in the learning stage group (8% vs. 0.4%, p= 0.0001). The global rate of complications for the learning stage group was 14%, and for the mastery stage group was 6.6% (p= 0.08). CONCLUSIONS: After the first 50 cases, the operative time, the length of stay, and the overall rate of complications decreased, being especially significant the decrease in the duodeno-ileal anastomosis leakage rate after reaching the learning curve.

Long-Term Outcomes of Sleeve Gastrectomy: Weight Recurrence and Surgical Non-responders.

INTRODUCTION: Sleeve gastrectomy (SG) is an effective procedure with remarkable weight loss and low complication rates. However, up to 30% of cases require revisional surgery in non-responders or patients who experience weight recurrence. We aim to report the rate of weight recurrence/non-responders (WR/NR) in patients who underwent SG and had more than 5 years of follow-up. METHODS: We performed a multicenter retrospective study of patients who underwent initial SG from 2008 to 2017. Patient demographics and weight loss outcomes up to 12 years after SG were collected. Surgical non-responders were defined as 20% weight regain compared to maximum weight loss. A chi-square test for categorical variables and a two-sample t-test for continuous variables were used. Data are summarized as mean ± standard deviation. RESULTS: From a total of 1263 patients, we included 339 patients (78% female, age 47.3 ± 11.2 years; baseline weight 125.8 ± 27.6 kg) with at least 5 years of follow-up (mean follow-up of 7.1 ± 1.8 years) (Table 1). Surgical non-response was demonstrated in 15.9% of patients (n=54) and 64.0% (n=217) had weight recurrence after SG (Fig. 1). There was a statistically significant difference in history of hypertension (p=0.046) and diabetes (p=0.032) as well as %TBWL at 1 year (p=0.005) and at longest follow-up (p<0.001) between patients who experienced WR/NR and those who did not. CONCLUSIONS: Only 20% of patients who underwent SG and followed up for more than 5 years were able to maintain appropriate weight loss.

Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol.

INTRODUCTION: Enhanced recovery after bariatric surgery pathways are associated with improved postoperative outcomes. This study aims to assess efficacy and safety of three novel protocol contributions (transversus abdominis plane blocks, ketamine and fosaprepitant), as well as their impact on length of stay (LOS) and on postoperative complications. METHODS: Effectiveness and safety were retrospectively investigated in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) over a 6-year period in a single institution. Group 1 patients were not exposed to any of our suggested interventions, whereas Group 2 were exposed to all of three. RESULTS: Between January 2015 and August 2021, 1480 patients underwent primary SG (77.6%) or RYGB (22.4%); of those, 1132 (76.5%) and 348 (23.5%) were in Groups 1 and 2, respectively. Mean BMI and age were 45.87 versus 43.65 kg/m2 and 45.53 versus 44.99 years in groups 1 and 2, respectively. Suggested interventions were associated with lower operative times (84.79 ± 24.21 vs. 80.78 ± 32.8 min, p = 0.025). In Group 2, the mean LOS decreased in 0.18 day (1.79 ± 1.04 vs. 1.60 ± 0.90; p = 0.004). Overall complication rates were 8% and 8.6% for groups 1 and 2, respectively; readmission rates were 5.7% (64 pts) vs. 7.2% (25 pts), p > 0.05. Reoperations were less prevalent in Group 2 (1.5% vs. 1.1%; p = 0.79). CONCLUSION: Focus on optimized pain management, allied to a superior PONV control, may be relevant contributors for a lower LOS without negative impacts in complications rates.

Impact of Emend on Perioperative Bariatric Surgery Antiemetic Utilization, Patient Satisfaction, and Costs.

PURPOSE: Postoperative nausea and vomiting (PONV) is one of the most common adverse effects of anesthesia and surgery, resulting in patient discomfort and dissatisfaction. Latest research has demonstrated the efficacy of NK-1 receptor antagonists in PONV management and its use in chemotherapy nausea prophylaxis. The authors of this article would like to provide evidence to support the use fosaprepitant, as monotherapy, in postoperative care, replacing a polypharmacological standard of care regimen. METHODS: This was a retrospective chart review of 400 patients who received standard of care antiemetic regimen or received fosaprepitant (No-Fosaprepitant vs. Fosaprepitant groups, respectively). The primary outcome of this study is to evaluate the impact of fosaprepitant (administered intravenously) on perioperative antiemetic use, treatment cost, and patient satisfaction. RESULTS: Total PONV medication cost decreased with the replacement of standard of care regimen for fosaprepitant, from 46.47±20.54 United States Dollars in the no-Fosaprepitant group to 25.69±14.84 United States Dollars in the Fosaprepitant group. There was a significant reduction in antiemetic doses between groups; 0.37±0.745 versus 7.61±5.202 for ondansetron ( P =0.001), 92±1.279 versus 2.21±2.399 for promethazine ( P =0.001), 0.25±0.685 versus 1.41±0.577 for scopolamine patch ( P =0.001), and 0.05±0.218 versus 1.14±0.398 for dexamethasone ( P =0.001). Patient satisfaction, measured by a questionnaire, was a 11.6% higher in the Fosaprepitant group. CONCLUSION: Fosaprepitant is a relevant alternative in preventing and treating PONV in patients who underwent bariatric/metabolic surgical procedures.

Impact of Perioperative Ketamine on Postoperative Bariatric Surgery Opioid Use and Length of Stay.

SETTINGS: Postoperative pain management is an ever-growing challenge with the rise of the opioid crisis. Ketamine is an NMDA channel blocker, considered an alternative to perioperative opioid use; small concentrations are safe. Objective: The primary objective of this study was to evaluate the impact of perioperative ketamine administration on postoperative opioid use and the length of hospital stay in bariatric patients. METHODS: Four hundred (366) charts were retrospectively reviewed; of those, 187 received ketamine and were placed in the Ketamine group, 179 received standard-of-care pain management and were part of the No-Ketamine group. Data was collected using medical databases from July 2020 to January 2021. RESULTS: A greater length of stay was recorded in the No-Ketamine group (45.67±20.6 hours) when compared with the Ketamine group (40.6±14.3 hours); P <0.05. The Ketamine group had a mean MME of 17.5±16.5 whereas the No-Ketamine had a mean MME of 22.3±17.7, P <0.05. CONCLUSIONS: Ketamine may be a feasible alternative to reduce opioid use and hospital length of stay. We believe that ketamine can be an important contribution to ERABS pathways, being responsible for improved outcomes after bariatric/metabolic surgical procedures.

Robot-assisted duodenal switch with DaVinci Xi: surgical technique and analysis of a single-institution experience of 661 cases.

Metabolic and bariatric surgery is an effective treatment for the management of obesity and related comorbidities. Although the duodenal switch has demonstrated superior results in terms of resolution of obesity-related comorbidities and weight loss, it is one of the less performed procedures. The use of robotic surgical platforms offers many advantages in obese patients and is particularly useful in technically demanding procedures such as duodenal switch. Observational, retrospective and analytical study of cases corresponding to robot-assisted duodenal switch performed between 2016 and 2021. We describe our technique using the system DaVinci Xi. Operative and perioperative variables, postoperative complications, and readmission rate were determined. A total of 661 patients underwent duodenal switch which correspond to the 20.7% of the total bariatric procedures performed in this period. A clear decrease in surgical time and length of stay was observed as the number of cases progressively increased. The complication rate during the first 30 days was 9.1%. Among these, only 1.9% corresponded to major complications, being strictures the most frequent (0.9%), followed by leaks (0.45%). Readmission rate in this period was 6.1%. Between 30 and 90 days postoperatively, the complication rate was 0.91%. Robotic-assisted duodenal switch is a safe surgery with a low complication rate. This procedure is highly effective in terms of durable weight loss in obese and super-obese patients. Robotic DaVinci Xi system allows surgeons to achieve a high level of proficiency and master technique resulting in reduction of surgical time and length of stay.

Single- Versus Double-Anastomosis Duodenal Switch: Outcomes Stratified by Preoperative BMI.

PURPOSE: Describe and analyze the safety and weight loss performance of biliopancreatic diversion and duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), verifying any possible superiority according to preoperative BMI. METHODS: Retrospective review of patients who underwent primary SADI-S or BPD-DS in three bariatric centers. Study groups were further stratified according to preoperative BMI (subgroup 1: BMI < 50; subgroup 2: 50 ≤ BMI < 55; subgroup 3: BMI ≥ 55). RESULTS: Four hundred and sixty patients underwent BPD-DS (n = 220) or SADI-S (n = 240). The mean LOS was 3.48 ± 3.7 and 3.13 ± 2.3 days for BPD-DS and SADI-S respectively (p = 0.235). The mean operative time was shorter in the SADI-S group (167.25 ± 33.6 vs 140.85 ± 56.7 min) (p < 0.00). The mean %EWL was 44.2, 62.4, and 69.4 for the BPD-DS group and 48.4, 64.5, and 67.1 for the SADI-S group at 6, 12, and 24 months respectively. The mean %TBWL was 25, 35.9, and 40.3 for the BPD-DS group, and 26.2, 35, and 36.9 for the SADI-S group at 6, 12, and 24 months respectively. Overall complication rates were comparable between BPD-DS and SADI-S groups (14% vs 18%) (p = 0.219). SADI-S showed greater emergency department visits (17% vs 7%) (p = 0.005); similar readmission rates (6% vs 7%) (p = 0.80); similar reoperation rates (3% vs 7%) (p = 0.102); and similar mortality rate (0.9% vs 0.4%), after BPD-DS and SADI-S respectively. CONCLUSION: BPD-DS achieved greater %TBWL at 2 years, but no superiority was perceived among study subgroups. SADI-S and BPD-DS showed similar overall complication rates.

Duodenal Switch Conversion in Non-responders or Weight Recurrence Patients.

INTRODUCTION: Several modalities have been proposed to tackle insufficient weight loss and weight regain after bariatric surgery; we aimed to evaluate efficacy and safety of duodenal switch conversion as a salvage procedure. MATERIAL AND METHODS: Data from patients who underwent duodenal switch conversions (n = 50) were retrospectively studied. Excess weight loss % and total body weight loss % were compared between primary procedure and duodenal switch conversion. Overall complication, emergency department visits, readmissions, reoperation, and mortality rates were described, analyzed, and compared to the current literature. RESULTS: Every excess weight loss % and total body weight loss % comparison at 6, 12, and 24 months, demonstrated a statistically significant superiority in weight loss after duodenal switch conversion (p < 0.05). The mean operative time of adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (1 and 2 stages) conversions to duodenal switch were 208, 146, 187, and 152 min, respectively, while the mean length of stay was 3.38 days. No statistically significant differences were perceived regarding the primary procedure. The overall complication rate was 18% (9 patients); 3 patients (6%) had 1 emergency department visit; readmissions accounted for 12% of cases (6 patients); the reoperation rate was 10% (5 patients); no fatal outcomes were recorded. CONCLUSION: Duodenal switch conversions are an effective salvage procedure for insufficient weight loss and/or weight regain after adjustable gastric band, sleeve gastrectomy, and Roux-en-Y gastric bypass; it is also safe, associated to low readmission, reoperation, and mortality rates.

ANTI-REFLUX PROCEDURES AFTER ROUX-EN-Y GASTRIC BYPASS.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention. AIM: To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis. METHODS: A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed. RESULTS: Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%. CONCLUSIONS: Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

Hydatid cyst in the neck, an unusual localization of the disease: A case report.

INTRODUCTION AND IMPORTANCE: Hydatid cyst disease or hydatidosis is an old parasitic disease. Humans represent an accidental intermediate host. Neck is considered a rare location of hydatid cysts. It is usually overlooked as a deferential diagnosis in any cystic lesion in the neck, even in the regions where the disease is considered endemic. CASE PRESENTATION: A 26 year old female was admitted to Al-Mouwasat Hospital with the complaint of an anterior cervical mass causing compressive symptoms. Examinations determined a big cystic lesion at expense of the thyroid gland and extended to the level of aortic arch, in addition to smaller lesions in the two thyroid lobes. Multinodular goiter was diagnosed. However, Hydatid cyst disease was suspected during surgery. Cystectomy and total thyroidectomy were performed. Histopathology confirmed the diagnosis of hydatid cyst disease. CLINICAL DISCUSSION: Hydatid cyst disease in the neck is usually asymptomatic unless it compresses near structures. Histopathological study makes the definitive diagnoses. The best treatment of thyroid hydatid cysts is total surgical excision of all cysts with intensive care not to spread the disease. CONCLUSION: Hydatid cyst disease in the neck is extremely rare. Hydatid cyst should be included in differential diagnosis of cystic lesions in the neck especially in patients from endemic countries. Post-operative surveillance is important to diagnose the complete healing or recurrence of hydatid disease in operated or other locations but also for follow up of replacement therapy after total thyroidectomy as the patient require lifelong thyroid hormone replacement.

Anti-reflux procedures after roux-en-y gastric bypass / Procedimentos anti-refluxo após bypass gástrico em y-de roux

ABSTRACT Background: Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention. Aim: To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis Methods: A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed. Results: Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%. Conclusions: Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

RESUMO Racional: O bypass gástrico em Y-de-Roux (RYGB) tem sido o procedimento bariátrico de escolha para pacientes com refluxo sintomático - e é conhecido por ser eficaz na redução da necessidade de medicação anti-refluxo no pós-operatório. No entanto, um pequeno número de pacientes com RYGB ainda pode desenvolver sintomas de refluxo graves que requerem uma intervenção cirúrgica. Objetivo: Examinar e descrever a população de pacientes que requer procedimento anti-refluxo após RYGB avaliando dados demográficos, características, sintomas e diagnóstico. Métodos: Revisão retrospectiva de prontuários foi realizada em 32 pacientes submetidos a hérnia hiatal e / ou fundoplicatura Nissen após RYGB em 1º de julho de 2014 a 31 de dezembro de 2019. Os pacientes foram identificados por meio do banco de dados MBSAQIP e seus prontuários eletrônicos foram revisados. Resultados: A maioria dos pacientes era do sexo feminino (n = 29 - 90,6%). A média de idade foi de 52,8 anos e o índice de massa corporea (IMC) médio de 34,1 kg / m2 na época do procedimento anti-refluxo. Os pacientes foram submetidos ao procedimento anti-refluxo em média 7,9 anos após o procedimento do BGYR. A porcentagem média de perda do excesso de IMC durante o tempo entre o BGYR e o procedimento anti-refluxo foi de 63,4%. Conclusões: Pacientes do sexo feminino com perda de peso significativa podem desenvolver sintomas graves de refluxo anos após o BGYR. Sintomas de refluxo após RYGB não devem ser negligenciadas. Acompanhamento cuidadoso e tratamento adequado (incluindo intervenção cirúrgica) são necessários para essa população.

Conversion of Laparoscopic Adjustable Gastric Banding to Gastric Bypass: a Comparison to Primary Gastric Bypass.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) has a considerable failure rate. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the rescue options. This study aims to compare the complication rates and outcomes between LAGB converted to LRYGB and primary LRYGB. MATERIALS AND METHODS: A retrospective analysis was performed in all patients converted from LAGB to LRYGB between January 2007 and March 2017. This group was compared to a matched cohort of primary LRYGB patients operated during the same period. Early and late complications, weight loss, and improvement of comorbidities were analyzed. RESULTS: One hundred sixty-one revisional LRYGB patients were compared to a similar number of primary LRYGB patients. Preoperative age, gender distribution, weight, and BMI were comparable. Mean operative time was longer in the revisional group (137.7 vs. 112.7 min, respectively, P < 0.001). The overall early complication rates were comparable between the groups (7.5 vs. 11.8%, P = 0.16), including postoperative leak rate (0.62%). Follow-up of at least 6 months was attained in 78% of the patients. Revisional cases demonstrated less weight loss (61.5 vs. 73.5%EWL, respectively, P = 0.004) and slightly less improvement of comorbidities (75.0 vs. 85.7%, respectively, P = 0.09). The late complication rate was comparable (8.1 vs. 8.1%, P = 1.0). CONCLUSION: Albeit longer operating time, revision of LAGB to LRYGB is a safe procedure, with similar complication rates when compared to primary LRYGB. Although revisional LRYGB does result in less weight loss than primary LRYGB, the procedure's safety makes it a very plausible option as a rescue operation for failed LAGB.

Assessing risk factors, presentation, and management of portomesenteric vein thrombosis after sleeve gastrectomy: a multicenter case-control study.

BACKGROUND: Portomesenteric vein thrombosis (PMVT) is a rare complication of laparoscopic sleeve gastrectomy. OBJECTIVES: To identify incidence, patient factors, diagnosis, and treatment of PMVT after laparoscopic sleeve gastrectomy in a large administrative data registry. SETTING: Academic Hospitals and Private Practices, United States. METHODS: A retrospective chart review of 5538 sleeve gastrectomy patients between January 1, 2008 and September 30, 2016 was performed at 5 bariatric centers in the United States. A total of 11 patients were identified as developing PMVT, and 3 controls for each patient were selected by matching age, sex, preoperative body mass index, and center. RESULTS: After adjusting for confounding variables, 2 patient factors significantly impacted the risk of PMVT after sleeve gastrectomy including personal history of malignancy (odds ratio 62, 95% confidence interval (CI) 1.4-99.9), and type 2 diabetes (odds ratio 12.7, 95% CI 1.2-137.3) compared with controls. Mean period from laparoscopic sleeve gastrectomy to presentation of PMVT was 19.3 ± 15.11 days (range, 8-62). All patients except 1 complained of abdominal pain as the main presenting symptom. Other complaints included nausea and vomiting, no bowel movement, decreased appetite, diarrhea, and dehydration, and leukocytosis was present in 45.5% of the patients. All diagnoses were made by using computed tomography. All initial treatments were anticoagulation, heparin drip being the most common method (90.9%). Of patients, 9 (81.8%) required a secondary anticoagulation therapy, and 1 (9.1%) patient required a reoperation. CONCLUSION: Incidence of PMVT is low after sleeve gastrectomy. A personal history of malignancy and type 2 diabetes increase the risk of PMVT. Increasing abdominal pain in a context of dehydration is common presenting symptoms with diagnosis confirmed by computed tomography. Anticoagulation is the standard treatment. There was no mortality associated with the occurrence of PMVT in this cohort.

Ultrasound evaluation of visceral and subcutaneous fat reduction in morbidly obese subjects undergoing laparoscopic gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass: a prospective comparison study.

BACKGROUND: Visceral fat (VF) plays a major role in the development of metabolic syndrome associated with obesity. The aim of our study is to compare VF and subcutaneous fat (SCF) reduction measured by ultrasonography (US) after laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-En-Y gastric bypass (LRYGB). METHODS: Thirty-nine morbidly obese patients were prospectively evaluated by US before surgery and 3, 6, and 12 months following surgery to determine VF and SCF thickness. RESULTS: Three statistically comparable groups of morbidly obese patients underwent LRYGB (n = 13), LSG (n = 15), and LAGB (n = 11). The three groups did not differ in initial age, gender, body mass index (BMI), VF, or SCF. Final excess weight loss (EWL%) was highest after LSG and LRYGB followed by LAGB (81 ± 5.8 vs. 69.5 ± 4.5 vs. 43.4 ± 5.2, p < 0.001). LSG and LRYGB were significantly more efficient in VF reduction (ΔVF) compared with LAGB (7.1 ± 0.5 vs. 5.6 ± 0.6 vs. 3.6 ± 0.8, p = 0.004). SCF reduction (ΔSCF) was also highest after LSG followed by LRYGB and LAGB (3 ± 0.2 vs. 2.2 ± 0.4 vs. 1.9 ± 0.4, p = 0.08). The change in fat distribution, determined as Δ(VF/SCF), showed a preferential VF reduction in the LSG and LRYGB patients compared with patients that underwent LAGB (0.59 ± 0.1 vs. 0.52 ± 0.2 vs. 0.19 ± 0.2, p = 0.42). In a subgroup analysis comparing only LSG to LRYGB, no statistically significant difference was seen in EWL%, ΔVF, ΔSCF, or in fat distribution Δ(VF/SCF). CONCLUSION: LSG and LRYGB show better preferential and overall VF reduction than LAGB. US may serve as a simple tool of evaluating postoperative fat distribution.