1568 A Case of Small Bowel Intussusception Occurring Six Years After Laparoscopic RYGB

Introduction We present a case of small bowel intussusception occurring in a female who had previously undergone Laparoscopic RYGB. Few case reports of retrograde intussusception occurring in pregnant patients with a history of LRYBG have been published. Up to our knowledge, this is the first case of this rare complication presenting in the postnatal period. Case report Our patient, a female in her thirties, gave birth to a healthy baby via caesarian section six years after her LRYGB. On the day following her operation, she experienced epigastric severe, progressive abdominal pain associated with nausea and vomiting. Abdominal examination showed epigastric and left upper quadrant tenderness, hypoactive bowel sounds and no palpable masses. Small bowel obstruction was suspected. A nasogastric tube was inserted and an abdominal CT scan with oral contrast was ordered. The CT scan showed multiple concentric segments of small bowel loops representing the intussusceptum pulled into the intussuscipiens, giving the classic doughnut sign. The patient was subsequently taken to theatre for a laparotomy. The mass was comprised of the biliopancreatic limb which was dilated as the common limb was retrogradely intussuscepting into it. The bowel was ischemic and remained so after manual reduction. A 45cm ischemic segment was resected and then primary re-anastomosis was done. Her postoperative course was unremarkable. Discussion Intussusception can present years after the original surgery, and imaging is not always reliable. Seeing as bariatric surgery is getting more popular, physicians should be well aware of this serious complication as delay in diagnosis increases morbidity and mortality.

Roux-en-Y Gastric Bypass and Antipsychotic Therapeutic Drug Monitoring: Two Cases

Many patients with psychiatric conditions undergo bariatric surgery. The Roux-en-Y gastric bypass (RYGB) procedure alters medication pharmacokinetic properties and may have significant impact on drug response. Our report is the first to describe atypical antipsychotic therapeutic drug monitoring in patients who have undergone RYGB. The first patient is a 53-year-old female with a stable psychiatric condition undergoing a laparoscopic RYGB. Her medications prior and following the procedure include bupropion, fluvoxamine, lurasidone, methylphenidate, oxcarbazepine, and verapamil. A concentration steady-state lurasidone concentration obtained prior to the procedure was 20 ng/mL and returned at 8.1 ng/mL, 29 days after surgery. The second patient is a 42-year-old female psychiatric inpatient who had previously undergone an RYGB procedure. Medications on admission included phenytoin, oxcarbazepine, risperidone, and venlafaxine. The patient was believed to be a good candidate for a long-acting antipsychotic and paliperidone was chosen. After concentration-steady-state on 6 mg oral paliperidone, a 23.5-hour trough level was drawn. The patient was noted to be improved on the oral paliperidone, the paliperidone long-acting injection was given, and the patient was discharged. After discharge, the paliperidone concentration returned very low at 1.1 ng/mL. We describe the contributions of drug–drug interactions, medication release mechanisms, and food coadministration that may have affected our therapeutic drug monitoring. Our therapeutic drug monitoring results need to be replicated prior to use in the general population but suggest that oral extended-release drug formulations are particularly poor choices and that nonoral antipsychotic formulations may be preferred in some patients who have undergone RYBG.

Health benefits and risks during 10 years after Roux-en-Y gastric bypass

Background Long-term evaluations 10 years after Roux-en-Y gastric bypass (RYGB) are limited. We report the development in weight and cardiovascular risk factors during 10 years after laparoscopic RYGB, with evaluation of gastrointestinal symptoms and quality of life (QoL) at 10-year follow-up. Methods We performed a prospective longitudinal cohort study. Patients operated with laparoscopic RYGB from May 2004 to November 2006 were invited to 10-year follow-up consultations. Gastrointestinal Symptom Rating Scale (GSRS) questionnaire and two QoL questionnaires were used for analyses of gastrointestinal symptoms and QoL. Results A total of 203 patients were operated; nine (4.4%) died during follow-up. Of 194 eligible patients, 124 (63.9%) attended 10-year follow-up consultations. Percent excess weight loss (%EWL) and percent total weight loss (%TWL) at 10 years were 53.0% and 24.1%, respectively. %EWL > 50% was seen in 53.2%. Significant weight regain (≥15%) from 2 to 10 years was seen in 63.3%. Remission rates of type 2 diabetes, dyslipidemia, and hypertension were 56.8%, 46.0%, and 41.4%, respectively. Abdominal operations beyond 30 days after RYGB were reported in 33.9%. Internal hernia and ileus (13.7%) and gallstone-related disease (9.7%) were the most common causes. Vitamin D deficiency (<50nmol/L) was seen in 33.3%. At 10 years, bothersome abdominal pain and indigestion symptoms (GSRS scores ≥3) were reported in 42.9% and 54.0%, respectively, and were associated with low QoL. Conclusion We observed significant weight loss and remission of comorbidities 10 years after RYGB. Significant weight regain occurred in a substantial subset of patients. Gastrointestinal symptoms were common and negatively impacted QoL.

Perforated duodenal ulcer after gastric bypass: a challenging diagnosis

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed surgeries for morbid obesity. Perforated duodenal ulcers are very rare in these patients (with a 0.25% incidence reported) and the diagnosis can be challenging. We report a case of a 43-year-old woman who presented with severe acute abdominal pain to the emergency department. She had undergone a laparoscopic RYGB 5 years previously. Exploratory laparoscopy revealed a duodenal perforation, which was repaired by primary closure. As Helicobacter pylori has been implicated in the formation of ulcers in this population, eradication therapy should be started.

Bypass en Y-de-Roux sobre una funduplicatura de Nissen

Roux-en-Y gastric bypass (RYGB) effectively treats both obesity and gastroesophageal reflux disease (GERD). Unfortunately, some patients finally present for bariatric surgery have previously undergone Nissen fundoplication due to GERD. Conversion to EYGB after Nissen fundoplication is safe and effective, but is associated with greater morbidity and longer operative time and hospital stay. A 50-year-old female patient with a body mass index (BMI) of 40.4 kg/m2 was evaluated for bariatric surgery. She had a history laparoscopic Nissen fundoplication seven years before. We report a case of laparoscopic take-down of Nissen fundoplication and conversion to RYGB. A previous fundoplication is not a contraindication for laparoscopic RYGB. These procedures should be performed by well-trained surgeons and laparoscopic approach should be the method of choice.

Management of Injury to the Common Bile Duct in a Patient with Roux-en-Y Gastric Bypass

Introduction. Most surgeons prefer Roux-en-Y hepaticojejunostomy (RYHJ) for biliary reconstruction following a common bile duct (CBD) injury. However, in patients with a Roux-en-Y gastric bypass (RYGB) a RYHJ may be technically challenging and can interfere with bowel physiology induced by RYGB. The use of a hepaticoduodenostomy (HD) resolves both these issues.Presentation of Case. We present a case of CBD injury during laparoscopic cholecystectomy one year after laparoscopic RYGB for morbid obesity. Due to adhesions and previous surgery with RYGB, we did not want to interfere with the RYGB physiology by anastomosing the CBD to the jejunum or ileum. Succeeding a full Kocher’s maneuver we performed biliary reconstruction by a tension-free end-to-side HD. The postoperative recovery was uneventful and the patient was discharged after eight days. At four-month follow-up, the patient had stable weight and normal laboratory test results. MRCP demonstrated normal intra- and extrahepatic bile ducts with status after HD.Discussion. We propose that HD should be considered in treatment of CBD injury in post-RYGB patients as it may reduce the risk of interfering with the post-RYGB physiology.

Early Outcomes of Roux-en-Y Gastric Bypass in a Publically Funded Obesity Program

Background. There is limited literature assessing the outcomes of bariatric surgery in a publically funded, North American, multidisciplinary bariatric program. Our objective was to assess outcomes of roux-en-Y gastric bypass (RYGB) in a publically funded bariatric program through a retrospective review of patient records. Methods. 293 patients spent a median of 13 months attending a multidisciplinary obesity clinic prior to undergoing laparoscopic RYGB surgery. The hospital was a Canadian, publically funded, level 2 trauma center with university teaching services. Results. 79% of the patients were female and the average BMI at first visit to clinic was 55.3 kg/m2. The average decrease in BMI was 19.2±0.9 kg/m2. This was an average absolute weight loss of 56.1 kg or 35.5% of initial weight. The average excess weight loss was 63.4±20.4%. Improvement or resolution of obesity related comorbidities occurred in 65.9% of type 2 diabetics and in 50% of hypertensive patients. Conclusion. Despite this being an unconventional setting of a publically funded program in a large Canadian teaching hospital, early outcomes following RYGB were appropriate in severely obese patients. Ongoing work will identify areas of improvement for enhanced efficiencies within this system.

Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy Achieve Comparable Weight Loss at 1 Year

Laparoscopic sleeve gastrectomy has gained popularity as a weight loss surgical option for morbidly obese patients. Although initial studies have shown weight loss and comorbidity resolution comparable to those after laparoscopic Roux-en-Y gastric bypass (RYGB), many of these studies are limited by the small patient size. Thus, the purpose of this study was to compare the outcomes of laparoscopic sleeve gastrectomy and laparoscopic RYGB. A retrospective chart review of all morbidly obese patients who underwent laparoscopic RYGB or sleeve gastrectomy between 2007 and 2009 at an HMO hospital was conducted. Data points collected included age, gender, completion of a preoperative weight loss program, initial body mass index (BMI), pre- and postoperative weights, and presence of diabetes mellitus (DM), hypertension (HTN), osteoarthritis, obstructive sleep apnea, and gastroesophageal reflux disease (GERD). Outcomes measures included excess weight loss, resolution of comorbidities, postoperative complications, and mortality. A total of 345 laparoscopic RYGBs and 192 sleeve gastrectomies were performed. On average, the patients who received RYGB were younger (46 vs 48 years, P = 0.05) and had higher BMI (47 vs 43 kg/m2, P < 0.0001). There was a higher incidence of DM in the RYGB group (32 vs 22%, P = 0.01), whereas the incidences of HTN and GERD were similar in both surgical groups. Ninety-three per cent of the patients who underwent RYGB and 90 per cent of the patients who underwent sleeve gastrectomy completed a preoperative weight loss program. The median length of hospital stay for both groups was 3 days. The complication rate in both groups was 9 per cent. The incidence of gastric leak was 1 per cent in both groups. There was only one mortality, which occurred in the RYGB group. The postoperative resolution of DM was comparable in both groups. The RYGB group had greater resolution of HTN (48 vs 34%, P = 0.03) and GERD (73 vs 34%, P < 0.0001). At 12 months, sleeve gastrectomy achieved superior excess weight loss compared with RYGB (72 vs 61%, P = 0.0015). After adjusting for age and BMI, the excess weight loss for RYGB and sleeve gastrectomy was similar at 12 months (t parameter estimate -0.06, P = 0.08). Laparoscopic RYGB and sleeve gastrectomy had comparable postoperative morbidity and mortality rates. At 1 year, sleeve gastrectomy achieved only slightly greater weight loss. The two operations are both legitimate standalone bariatric procedures and their applications need to be based on individual patient characteristics and needs.

Vitamin D absorption: consequences of gastric bypass surgery

BackgroundSevere vitamin D deficiency is a common finding in morbid obesity, and the incidence increases markedly after RYGB. Normalization of vitamin D levels after RYGB is difficult to achieve because the degree of surgery-induced malabsorption is not known.ObjectiveTo develop a test that quantifies the changes in intestinal cholecalciferol absorption induced by Roux-en-Y gastric bypass (RYGB) surgery.MethodsAbsorption characteristics of cholecalciferol were studied in 14 morbidly obese, premenopausal women before and 4 weeks after laparoscopic RYGB. Serum cholecalciferol levels were measured at baseline and 1, 2, 3, and 14 days after a single oral dose of 50 000 IU solubilized cholecalciferol.ResultsPeak serum cholecalciferol levels were observed on day 1 in all patients. They were 26.6±3.7% lower after RYGB (P=0.02). Inter-individual variability was high.ConclusionPeak cholecalciferol levels are reduced by about 25% after RYGB. Further analysis suggested that the timing of sampling in the current study was not optimal. This might have caused an underestimation of the true decrease in cholecalciferol absorption induced by RYGB.