Gastric bypass after liver transplantation.

Few data are available for assessing the outcomes of bariatric surgery for patients who have undergone orthotopic liver transplantation (OLT). The University of Minnesota bariatric surgery database and transplant registry were retrospectively reviewed to identify patients who had undergone OLT and then open Roux-en-Y gastric bypass (RYGB) surgery between 2001 and 2009. Comorbidity-appropriate laboratory values, body mass indices (BMIs), histopathology reports, and immunosuppressive regimens were collected. Seven patients were identified with a mean age of 55.4 ± 8.64 years and a mean follow-up of 59.14 ± 41.49 months from the time of RYGB. The mean time between OLT and RYGB was 26.57 ± 8.12 months. The liver disease etiologies were hepatitis C (n = 4), jejunoileal bypass surgery (n = 1), hemangioendothelioma (n = 1), and alcoholic cirrhosis (n = 1). There were 2 deaths for patients with hepatitis C 6 and 9 months after bariatric surgery due to multiple-organ dysfunction syndrome and metastatic esophageal squamous carcinoma, respectively. One patient with hepatitis C required a reversal of the RYGB because of malnutrition and an inability to tolerate oral intake. Four of the 7 patients had type 2 diabetes mellitus (T2DM), 4 had hypertension, and 6 patients had dyslipidemia. All patients were on immunosuppressive medications, but only 4 were on corticosteroids. Glycemic control was improved in all surviving patients with T2DM. The mean BMI was 34.27 ± 5.51 kg/m(2) before OLT and 44.34 ± 6.08 kg/m(2) before RYGB; it declined to 26.47 ± 5.53 kg/m(2) after RYGB. In conclusion, in this case series of patients undergoing RYGB after OLT, we observed therapeutic weight loss, improved glycemic control, and improved high-density lipoprotein levels in the presence of continued dyslipidemia. RYGB may have contributed to the death of 1 patient due to multiple-organ dysfunction syndrome.

Case-matched outcomes in bariatric surgery for treatment of type 2 diabetes in the morbidly obese patient.

OBJECTIVE: To compare the relative efficacy of medical management, the duodenal switch (DS), and the laparoscopic adjustable gastric band (LAGB) to the Roux-en-Y gastric bypass (RYGB) for treatment of type 2 diabetes mellitus (T2DM). BACKGROUND: The RYGB resolves T2DM in a high proportion of patients and is considered the standard operation for T2DM resolution in morbidly obese patients. However, no data exist comparing the efficacy of medical management and other bariatric operations to the RYGB for treatment of T2DM in comparable patient populations. METHODS: We performed a retrospective case-matched study of morbidly obese patients with T2DM who had undergone medical management (nonsurgical controls [NSC]; N = 29), LAGB (N = 30), or DS (N = 27) and were compared with matched T2DM patients who had undergone RYGB. Matching was performed with respect to age, sex, body mass index, and hemoglobin A1C (HbA1C). Outcomes assessed were changes in body mass index, HbA1C, and diabetes medication scores at 1 year. RESULTS: The Roux-en-Y gastric bypass produced greater weight loss, HbA1C normalization, and medication score reduction compared to both NSC and LAGB-matched cohorts. Duodenal switch produced greater reductions in HbA1C and medication score than RYGB, despite no greater weight loss at 1 year. Surgical complications were rarely life threatening. CONCLUSIONS: This study provides an important perspective about the comparative efficacy of LAGB, DS, and NSC to the RYGB for treatment of T2DM among obese patients. After 1 year of follow-up, RYGB is superior to NSC and LAGB with respect to weight loss and improvement in diabetes whereas DS is superior to RYGB in reducing HbA1C and medication score.

Small bowel obstruction and internal hernias during pregnancy after gastric bypass surgery.

Small bowel obstruction (SBO) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Internal hernia (IH) a potential problem associated with RYGB, can have severe consequences if not diagnosed. We present two cases of SBO due to IH during pregnancy after laparoscopic RYGB (LRYGB). Both patients underwent an antecolic, antegastric LRYGB. In both patients a Petersen's type IH was found. We reviewed the cases reported in the literature of SBO during pregnancy after RYGB. IH should always be ruled out in pregnant patients with previous RYGB and abdominal pain. Prompt surgical intervention is mandatory for a good outcome.

Analysis of vitamin levels and deficiencies in bariatric surgery patients: a single-institutional analysis.

BACKGROUND: Bariatric surgery patients are at risk for vitamin deficiencies. OBJECTIVES: Investigate the prevalence of deficiencies of vitamins A, B1, B12, D, and folate in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients in a single institution. SETTING: An academic medical center. METHODS: Retrospective chart reviews of 468 bariatric surgery patients (358 SG and 110 RYGB) were analyzed for vitamin levels, calcium, and parathyroid hormone. Both preoperative and postoperative measurements were obtained. RESULTS: Deficiency of vitamin D was the most common, seen in 27% preoperatively. Postoperatively, RYGB patients had a higher prevalence of vitamin D deficiency than SG patients (11.5% RYGB versus 5.2% SG within the first postoperative year, and 20.3% RYGB versus 13.4% SG after 1 year). Elevated parathyroid hormone was observed in 45% of RYGB patients after 1 year postoperatively. Vitamin A deficiency was uncommon preoperatively (2.7% SG versus 1.7% RYGB), but increased after surgery (9.4% SG versus 15.9% RYGB within 1 year postoperatively, and 5.2% SG versus 7.7% RYGB after 1 year). Vitamin B1 deficiency was observed in 8.1% SG versus 1.7% RYGB patients preoperatively and increased during the first year postoperatively (SG 10.5% and RYGB 13.7%), but improved after 1 year (7.2% SG versus 5.9% RYGB). Less than 2% of Vitamin B12 deficiencies and no folate deficiencies occurred in both SG and RYGB patients. CONCLUSIONS: The highest prevalence of vitamin B1 and A deficiencies were seen in the first year postoperatively. Vitamin B12 and folate deficiency were uncommon in our patients. Vitamin D deficiency improved after surgery, but elevated parathyroid hormone was common after RYGB.

Distal esophageal erosion after laparoscopic adjustable gastric band placement with nissen fundoplication takedown.

Although primary band placement is proven to be safe, gastric band placement after previous operations in the area of the gastroesophageal junction remains controversial. Erosion into the stomach has been described after failed vertical banded gastroplasty conversion to laparoscopic gastric banding (LAGB), but no reports in the English literature are available on erosion of an adjustable gastric band into the esophagus after conversion operations. To our knowledge, this is the first case report of distal esophageal erosion after LAGB placement with Nissen fundoplication takedown.

Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet.

BACKGROUND: Some alarming cases of hypoglycemic episodes in patients who have undergone Roux-en-Y gastric bypass have been reported. The syndrome of hyperinsulinemic hypoglycemia with nesidioblastosis after Roux-en-Y gastric bypass has been previously reported and is controversial. It has been suggested that subtotal or total pancreatectomy might be needed to control the symptoms in these patients. We have identified a similar cohort of patients with hyperinsulinemic hypoglycemia for whom we have reviewed patient characteristics and measured the glucose and insulin response to mixed meals. METHODS: We reviewed the charts of 14 patients identified by clinic follow-up who reported episodes consistent with hyperinsulinemic hypoglycemia (lightheadedness or loss of consciousness after a high-carbohydrate meal). All patients were given a mixed meal consisting of high carbohydrates on day 1 and a low-carbohydrate meal on day 2. The plasma glucose and serum insulin levels were measured before (fasting) and 30, 60, 90, 120, 150, and 180 minutes after the meal. RESULTS: After a high-carbohydrate meal, 12 of 14 patients demonstrated hyperglycemia associated with hyperinsulinemia at 30 minutes. These patients subsequently became hypoglycemic while the serum insulin was rapidly declining. After reaching a nadir at 120 minutes, the plasma glucose level corrected spontaneously. After a low-carbohydrate mixed meal, the patients demonstrated very little change in plasma glucose and only a modest increase in serum insulin. Of the 12 patients treated with a low-carbohydrate diet, 6 had substantive symptom improvement, and 10 exhibited at least some improvement. CONCLUSION: The hyperinsulinemic hypoglycemia noted in some patients after Roux-en-Y gastric bypass has many similarities to the dumping syndrome. A low-carbohydrate diet successfully improved symptoms in most of our patients. Approaches to treatment should involve a low-carbohydrate diet and alpha-glucosidase inhibitors rather than pancreatectomy.

Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en-Y gastric bypass.

BACKGROUND: To report the anatomic findings and outcomes in patients undergoing laparoscopic takedown of Nissen fundoplication with conversion to Roux-en-Y gastric bypass. METHODS: We reviewed the records of patients who underwent laparoscopic Nissen takedown with conversion to Roux-en-Y gastric bypass from January 2001 to April 2006 at the University of Minnesota Medical Center. RESULTS: Eleven patients were identified. Nine patients had gastroesophageal reflux disease preoperatively, of whom six underwent 24-hour pH monitoring. In 2 patients, the pH study findings were negative. Eight prior procedures had been performed laparoscopically. Eight patients were women. The mean age was 44 years. The average body mass index preoperatively was 44 kg/m(2) (range 35-61). The mean follow-up was 13.8 months (range 4-39). The body mass index at follow-up was 30.2 kg/m(2). The operative time was 349 minutes (range 222-624). The hospital length of stay was 3.4 days (range 2-6). No conversions to open surgery were required. No major short-term complications developed. Minor complications included wound or drain site infection in 3 patients, with abscess in 2, pressure sore of the lateral aspect of the foot in 1, pneumonia in 2, and marginal ulcer in 2 patients. No strictures were observed. One internal hernia occurred. Of the 9 patients with gastroesophageal reflux disease preoperatively, all had 100% improvement in symptoms, with complete resolution in 7 (78%). Wrap disruption was present in 5 (45%) of 11 patients. Herniation of an intact wrap had occurred in 1 patient. One patient had both herniation and wrap disruption. CONCLUSION: Laparoscopic conversion of Nissen fundoplication to Roux-en-Y gastric bypass is a feasible salvage operation for recurrent gastroesophageal reflux disease in the morbidly obese. The incidence of wrap disruption appears to be relatively high and the incidence of intact wrap herniation low in obese patients after failed Nissen fundoplication, suggesting that the mechanism of failure after primary antireflux surgery in obese patients may be different than that in normal-weight patients.

Roux-en-Y Gastric Bypass Acutely Decreases Protein Carbonylation and Increases Expression of Mitochondrial Biogenesis Genes in Subcutaneous Adipose Tissue.

BACKGROUND: Mitochondrial dysfunction in adipose tissue has been implicated as a pathogenic step in the development of type 2 diabetes mellitus (T2DM). In adipose tissue, chronic nutrient overload results in mitochondria driven increased reactive oxygen species (ROS) leading to carbonylation of proteins that impair mitochondrial function and downregulation of key genes linked to mitochondrial biogenesis. In patients with T2DM, Roux-en-Y gastric bypass (RYGB) surgery leads to improvements in glycemic profile prior to significant weight loss. Consequently, we hypothesized that improved glycemia early after RYGB would be paralleled by decreased protein carbonylation and increased expression of genes related to mitochondrial biogenesis in adipose tissue. METHODS: To evaluate this hypothesis, 16 obese individuals were studied before and 7-8 days following RYGB and adjustable gastric banding (AGB). Subcutaneous adipose tissue was obtained pre- and post-bariatric surgery as well as from eight healthy, non-obese individual controls. RESULTS: Prior to surgery, adipose tissue expression of PGC1α, NRF1, Cyt C, and eNOS (but not Tfam) showed significantly lower expression in the obese bariatric surgery group when compared to lean controls (p < 0.05). Following RYGB, but not after AGB, patients showed significant decrease in HOMA-IR, reduction in adipose protein carbonylation, and increased expression of genes linked to mitochondrial biogenesis. CONCLUSIONS: These results suggest that rapid reduction in protein carbonylation and increased mitochondrial biogenesis may explain postoperative metabolic improvements following RYGB.

Risk for hospital readmission following bariatric surgery.

BACKGROUND AND OBJECTIVES: Complications resulting in hospital readmission are important concerns for those considering bariatric surgery, yet present understanding of the risk for these events is limited to a small number of patient factors. We sought to identify demographic characteristics, concomitant morbidities, and perioperative factors associated with hospital readmission following bariatric surgery. METHODS: We report on a prospective observational study of 24,662 patients undergoing primary RYGB and 26,002 patients undergoing primary AGB at 249 and 317 Bariatric Surgery Centers of Excellence (BSCOE), respectively, in the United States from January 2007 to August 2009. Data were collected using standardized assessments of demographic factors and comorbidities, as well as longitudinal records of hospital readmissions, complications, and mortality. RESULTS: The readmission rate was 5.8% for RYGB and 1.2% for AGB patients 30 days after discharge. The greatest predictors for readmission following RYGB were prolonged length of stay (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 2.0-2.7), open surgery (OR, 1.8; CI, 1.4-2.2), and pseudotumor cerebri (OR, 1.6; CI, 1.1-2.4). Prolonged length of stay (OR, 2.3; CI, 1.6-3.3), history of deep venous thrombosis or pulmonary embolism (OR, 2.1; CI, 1.3-3.3), asthma (OR, 1.5; CI, 1.1-2.1), and obstructive sleep apnea (OR, 1.5; CI, 1.1-1.9) were associated with the greatest increases in readmission risk for AGB. The 30-day mortality rate was 0.14% for RYGB and 0.02% for AGB. CONCLUSION: Readmission rates are low and mortality is very rare following bariatric surgery, but risk for both is significantly higher after RYGB. Predictors of readmission were disparate for the two procedures. Results do not support excluding patients with certain comorbidities since any reductions in overall readmission rates would be very small on the absolute risk scale. Future research should evaluate the efficacy of post-surgical managed care plans for patients at higher risk for readmission and adverse events.

Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-en-Y gastric bypass.

BACKGROUND: Despite providing superb excess weight loss and increased resolution of comorbid diseases, such as type 2 diabetes mellitus, compared to other bariatric procedures, the duodenal switch/ biliopancreatic diversion (DS/BD) has not gained widespread acceptance among patients and physicians. In this study, we investigated outcomes, symptoms and complications among postsurgical DS patients compared to RYGB patients. METHODS: We used propensity scores to retrospectively match patients who underwent DS/BD between 2005 and 2010 to comparable Roux-en-Y gastric bypass (RYGB) patients. We then reviewed patient charts, and surveyed patients using the University of Minnesota Bariatric Surgery Outcomes Survey tool to track outcomes, comorbid illnesses and complications. RESULTS: One hundred ninety consecutive patients underwent primary DS/BD between 2005 and 2010 at the University of Minnesota Medical Center. There were 178 patients available for follow-up (93.7%) who were matched to 139 RYGB patients. Type 2 diabetes, hypertension, and hyperlipidemia all significantly improved in each group. Improvements were significantly higher in the DS/BD group. Percent total weight loss was not different between groups. Loose stools and bloating symptoms were more frequently reported among DS/BD patients. With the exception of increased emergency department visits among DS/BD patients (P < .01), overall complication rates were not significantly different between DS/BD and RYGB. There was no difference in mortality rates between the groups. CONCLUSION: The DS/BD is a robust procedure that engenders both superior weight loss and improvement of major comorbidities. Complication and adverse event rates are similar to those of RYGB.

Routine upper gastrointestinal imaging is superior to clinical signs for detecting gastrojejunal leak after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: There are myriad symptoms and signs of gastrojejunal leak; prompt recognition is essential. Many surgeons use clinical predictors to guide selective use of upper gastrointestinal imaging (UGI). The appropriate practice remains undefined. STUDY DESIGN: A review of patients who underwent primary laparoscopic Roux-en-Y gastric bypass between January 2002 and December 2008 was conducted. All underwent routine UGI studies on postoperative day 1. Actual gastrojejunal leak within 7 days of surgery (actual leak [AL], radiologic leaks), operative reports, patient charts, and postoperative vital signs were retrospectively reviewed. RESULTS: There were 2,099 operations. Eight ALs (0.43%) occurred without associated mortality. UGI was positive in 7 AL patients and falsely positive in 6 patients. The AL patients underwent laparoscopy on postoperative days 1 and 3 (n = 5 and n = 1, respectively), laparotomy on postoperative day 3 (n = 1), and peritoneal drainage (n = 1). False-positive UGIs prompted laparoscopy (n = 3) and close observation (n = 3). Pulse was 100 to 120 beats per minute in 2 patients and fever (>38.5°C) was present in 0 AL patients. AL patients had osteogenesis imperfecta (n = 1), macronodular cirrhosis (n = 1), positive bubble test (n = 3), and concomitant splenectomy (n = 1). No jejunojejunostomy leaks were identified. CONCLUSIONS: Routine UGI after laparoscopic Roux-en-Y gastric bypass has greater sensitivity than clinical signs for detecting gastrojejunal leak. Delay in the diagnosis of leakage can impact mortality, and this suggests that indications for routine UGI might still exist. Tachycardia is not a reliable early marker of leak. There might be risk factors for leak in addition to vital signs, including patient medical history or intraoperative events, which should prompt routine UGI on postoperative day 1.

Efficacy of the Roux-en-Y gastric bypass compared to medically managed controls in meeting the American Diabetes Association composite end point goals for management of type 2 diabetes mellitus.

BACKGROUND: The treatment goals recommended by the American Diabetes Association (ADA) for patients with type 2 diabetes mellitus include hemoglobin A1c (HbA1C) <7.0%, low-density lipoprotein (LDL) <100 mg/dL, and systolic blood pressure (SBP) <130 mmHg. Only 10% of conventionally treated patients reach these goals as a composite endpoint. The efficacy of the Roux-en-Y gastric bypass (RYGB) in meeting this composite endpoint has not been reported. METHODS: We compared our database of patients with type 2 diabetes undergoing RYGB to a database of patients with medically managed type 2 diabetes and at least 2 years of follow-up data. RESULTS: Ultimately, 152 RYGB patients were compared to 115 routine medical management (RMM) patients for whom data on the composite endpoint were available over 2 years. The results show significant decrease in body mass index (kilograms per square meter) in the RYGB group compared to the RMM group (P < 0.001). HbA1C, LDL cholesterol, and SBP all significantly improved in the RYGB group (all P ≤ 0.01) and did not demonstrate any significant change in the RMM group. Over 2 years, when evaluating all three endpoints, the RYGB group (10.5% to 38.2%, P < 0.001) demonstrated increased achievement of the ADA goals compared to the RMM group (13.9% to 17.4%, P = 0.47). There was a significant decrease in medication use in the RYGB cohort; however, discontinuation of medications was sometimes inappropriate. CONCLUSIONS: RYGB achieves the ADA composite endpoint more frequently than conventional therapy and with less medication.

Comparative effectiveness of bariatric surgery and nonsurgical therapy in adults with type 2 diabetes mellitus and body mass index <35 kg/m2.

BACKGROUND: Outcomes of bariatric surgery in patients with a body mass index (BMI) <35 kg/m(2) have been an active area of investigation. We examined the comparative effectiveness of Roux-en-Y gastric bypass (RYGB) to routine medical management (nonsurgical controls; NSCs) in achieving appropriate targets defined by the American Diabetes Association for type 2 diabetes mellitus (T2DM) in patients with class I obesity (BMI 30.0-34.9 kg/m(2)) T2DM at 1 year. METHODS: We identified patients undergoing RYGB (N = 17) with both class I obesity and T2DM and compared them to similar NSC (N = 17) treated in the Primary Care Center. Data were collected at baseline and 1 year for systolic blood pressure (SBP), as well as blood levels for low-density lipoprotein (LDL) cholesterol and hemoglobin A1c (HbA1c). RESULTS: After RYGB, BMI decreased from 34.6 ± 0.8 kg/m(2) to 25.8 ± 2.5 kg/m(2) (P < .001) and HbA1c decreased from 8.2 ± 2.0% to 6.1 ± 2.7% (P < .001). The NSC cohort had no significant change in either BMI or HbA1c. SBP and LDL did not significantly change in either group. The RYGB group had a decrease in medication use compared to the NSC group (P < .001). The RYGB group ceased the use of antihypertensive and antihyperlipidemia medications by 1 year despite abnormal values. CONCLUSION: RYGB can be performed in patients with both a BMI <35 kg/m(2) and T2DM with better weight loss, glycemic control, and fewer antihyperglycemic medications than NSC. Inappropriate cessation of medications may partially explain the persistent increase in both SBP and LDL after RYGB.

Roux-en-Y gastric bypass is associated with early increased risk factors for development of calcium oxalate nephrolithiasis.

BACKGROUND: Patients treated for obesity with jejunoileal bypass (JIB) experienced a marked increased risk of hyperoxaluria, nephrolithiasis, and oxalate nephropathy developing. Jejunoileal bypass has been abandoned and replaced with other options, including Roux-en-Y gastric bypass (RYGB). Changes in urinary lithogenic risk factors after RYGB are currently unknown. Our purpose was to determine whether RYGB is associated with elevated risk of developing calcium oxalate stone formation through increased urinary oxalate excretion and relative supersaturation of calcium oxalate. STUDY DESIGN: A prospective longitudinal cohort study of 24 morbidly obese adults (9 men and 15 women) recruited from a university-based bariatric surgery clinic scheduled to undergo RYGB between December 2005 and April 2007. Patients provided 24-hour urine collections for analysis 7 days before and 90 days after operation. Primary outcomes were changes in 24-hour urinary oxalate excretion and relative supersaturation of calcium oxalate from baseline to 3 months post-RYGB. RESULTS: Compared with their baseline, patients undergoing RYGB had increased urinary oxalate excretion (31 +/- 10 mg/d versus 41 +/- 18 mg/d; p = 0.026) and relative supersaturation of calcium oxalate (1.73 +/- 0.81 versus 3.47 +/- 2.59; p = 0.030) 3 months post-RYGB in six patients (25%). De novo hyperoxaluria developed. There were no preoperative patient characteristics predictive of development of de novo hyperoxaluria or the magnitude of change of daily oxalate excretion. CONCLUSIONS: This prospective study indicates that RYGB is associated with an earlier increase in urinary oxalate excretion and relative supersaturation of calcium oxalate than previously reported. Additional studies are needed to determine longterm post-RYGB changes in urinary oxalate excretion and identify patients that might be at risk for hyperoxaluria developing.