Laparoscopic Roux-en-Y gastric bypass in the elderly: feasibility, short-term safety, and impact on comorbidity and weight in 250 cases.

INTRODUCTION: In the elderly obese population, frequently suffering from multiple comorbidities, laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered a high-risk procedure. The aim of this study was to evaluate short-term safety (30-day hospital morbidity and mortality) of this procedure and its impact on weight and associated comorbidities in the medium term (type-two diabetes, hypertension, sleep apnea, hypercholesterolemia, and joint pain). METHODS: This study represents a retrospective analysis of all our Belgian patients older than 60 years of age who underwent a LRYGB between October 2004 and October 2012. Patient files were reviewed and patients were contacted by formal consultation or by phone for an update of their clinical status. Demographics, operative details, postoperative course, and the evolution of weight and associated comorbidities were registered. RESULTS: A total of 280 patients were included. A complete follow-up was available for 250 patients (89 %), of whom 161 were female and 89 male. Mean age, BMI, and hospital stay were 64.1 years (60-78 years), 41.9 kg/m(2) (27.4-68 kg/m(2)), and 4.3 days (2-19 days), respectively. There was no in-hospital mortality, 27 (10.8 %) patients suffered from early postoperative complications and 5 (2 %) patients needed to be readmitted. After a mean follow-up of 31.5 months, the mean excess weight loss was 59.3 % (range 21.9-120.1 %). Resolution or improvement of diabetes, hypertension, sleep apnea, hypercholesterolemia, and joint pain was seen in 94.6, 77.6, 88.0, 77.1 and 57.6 % respectively. CONCLUSION: LRYGB has an acceptable complication rate in the elderly. Since all obesity-related comorbidities improved during follow-up, there is a plea not to exclude this subgroup of patients from the well-known benefits of gastric bypass surgery.

Indications, safety, and feasibility of conversion of failed bariatric surgery to Roux-en-Y gastric bypass: a retrospective comparative study with primary laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is considered the "gold standard" revision procedure. The purpose of this study was to compare the surgical outcome of primary laparoscopic RYGB (pLRYGB) to revisional open or laparoscopic Roux-en-Y gastric bypass surgery (rRYGB). METHODS: A retrospective analysis of all patients who underwent pLRYGB or rRYGB from January 2003 to December 2009 has been performed. Demographics, indications for revision, and complications have been reviewed. The rRYGB and pLRYGB patients have been compared. RESULTS: Seventy-two patients underwent rRYGB, and 652 patients underwent pLRYGB. Mean follow-up was 35 and 45 months, respectively. Fifty-six rRYGB procedures were performed laparoscopically. The primary operations had consisted of laparoscopic gastric banding (n = 28), laparoscopic vertical banded gastroplasty (n = 19), laparoscopic sleeve gastrectomy (n = 6), laparoscopic RYGB (n = 3), and biliopancreatic diversion with duodenal switch (n = 16). Indications included weight regain (n = 29), malabsorption (n = 16), gastrogastric fistula (n = 5), band-associated problems (n = 3), and refractory stomal ulceration (n = 1). There was no significant difference in early or late postoperative complications when comparing rRYGB to pLRYGBP patients (11.1% vs. 5.52%, P = 0.069 and 19.4% vs. 24.2%, P = 0.465 respectively). Five rRYGB patients (7.04%) required reintervention (3 internal hernias, 1 ventral hernia, 1 laparoscopic exploration) compared with 101 pLRYGB patients (15.71%; P = 0.051). None of the patients died. Mean hospital stay was not significantly longer in the rRYGB group (5.38 vs. 4.95 days, P = 0.058). CONCLUSIONS: In our series, hospital stay, morbidity, and mortality of rRYGB were not significantly higher compared with pLRYGB. Furthermore, we believe that this type of revisional bariatric surgery should be performed in high-volume bariatric centers.

Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings.

BACKGROUND: Even though internal hernia (IH) after a laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-known entity for bariatric surgeons and radiologists, accurate diagnosis remains difficult. The aim of this study was to evaluate the sensitivity and specificity of ten different CT findings in patients with a proven internal hernia after a LRYGB. METHODS: A retrospective analysis of all LRYGB patients who underwent an explorative laparoscopy for abdominal pain has been performed. Preoperative CT scans were individually reviewed by two radiologists specialized in abdominal CT imaging in a randomized blind way. These results were compared with the operative reports. RESULTS: Between 2004 and 2013, 7,328 patients underwent a LRYGB. One hundred sixty nine of these patients underwent an explorative laparoscopy for abdominal pain after a LRYGB, 131 of which had a preoperative CT scan. Of these 131 patients, 72 suffered from an IH. Fifty-nine patients had no IH and served as control group. Mesenteric swirl was the best predictor with for reader 1 a sensitivity of 68% and specificity of 86% and for reader 2 a sensitivity of 89% and specificity of 63%. Other signs had an even larger interobserver variability. CONCLUSIONS: A CT scan can help in confirming the diagnosis of an IH, especially if a mesenteric swirl is present. However, since the presented sensitivities are variable and do not reach 100%, IH might be missed, implicating that a high index of suspicion with a low threshold for explorative laparoscopy/-tomy remains the cornerstone of appropriate treatment.

Postsurgery activation of dormant liver micrometastasis: a case report and review of literature.

BACKGROUND: We present the case of a 55-year-old woman who underwent a Whipple procedure for pancreatic adenocarcinoma. The preoperative work-up showed no signs of liver metastasis and confirmed the patient's operability, but at less than 40 days postoperatively there were diffuse liver metastasis present on CT. This rapid evolution raises the question whether current staging systems are adequate in determining a patient's operability. It also suggests an interaction between the primary tumor and the host and the existence of disseminated tumor cells. DISCUSSION: In this article, we give an explanation for the clinical evolution presented in our case using the "integrated organ" and the "concomitant resistance" hypotheses. We believe that, if these theories continue to prove their viability, the search for disseminated tumor cells will be essential for good clinical practice in this type of pathology.

Small bowel obstruction after antecolic antegastric laparoscopic Roux-en-Y gastric bypass without division of small bowel mesentery: a single-centre, 7-year review.

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen's space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.

Prophylactic cholecystectomy, a mandatory step in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass?

BACKGROUND: The aim of this study was to determine the incidence of symptomatic gallstone disease requiring cholecystectomy (CCE) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and to identify the peri-operative risk factors associated with postoperative symptomatic gallstone disease. METHODS: Between August 2003 and November 2009, 724 patients underwent LRYGBP at the Groeninge Hospital. Preoperative ultrasound was performed in 600 of 641 patients without history of CCE and 120 (20.0%) were diagnosed with cholecystolithiasis. RESULT: Six hundred twenty-five patients were included, 43(6.9%) developed delayed symptoms related to biliary disease. Of these 43 patients, 39 underwent post-LRYGBP CCE. Of these 39 patients, 9 (7.5%) had a positive ultrasound prior to LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGB of more than 50% of excess weight [HR (95% CI), 2.04 (1.04-4.28); p = 0.037) as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. CONCLUSIONS: Symptomatic gallstone disease occurred only in 6.9% of patients post-LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGBP of more than 50% of excess weight as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. Prophylactic CCE should not be recommended at the time of LRYGBP.

What is wrong in the cava? A rare cause of deep vein thrombosis.

When using cement in a hip arthroplasty, high intramedullary pressures are generated. This may lead to several complications, ranging from local extravasation to systemic complications such as the implantation syndrome. Until now, venous migration of cement after hip arthroplasty has never been associated with morbidity or mortality. We present a case in which cement pressurization led to migration of cement up to the level of the inferior vena cava with subsequent deep vein thrombosis.

Unilateral lower limb paralysis after aortobifemoral bypass graft for ruptured abdominal aortic aneurysm: a case report.

An 81-year-old man underwent an aortobifemoral bypass graft because of a ruptured abdominal aortic aneurysm. His postoperative recovery was complicated by unilateral lower limb paralysis caused by perioperative ischemia of the lumbosacral plexus. Ischemic lumbosacral plexopathy is an uncommon complication after infrarenal aortic surgery with serious morbidity. Despite a good surgical technique and knowledge of the vascularization of the spinal cord, its occurrence remains unpredictable.