Multimedia Library
The enemy of good is better, colonic obstruction post gastric bypass: an international video case series
We present 3 cases of transverse colon obstruction after antecolic-antegastric Roux-en-Y gastric bypass (RYGB) and describe the technical steps in relieving the obstruction. All patients have consented and approved to publish this work.Effects of body composition profiles on oncological outcomes and postoperative intraabdominal infection following colorectal cancer surgery
Anthropometric data as prognostic factors of colorectal cancer are promising but contradictory. The aim of this study was to assess the preoperative body composition profiles as predictive factors for postoperative, oncologic, and inflammation outcomes.Laparoscopic duodenojejunostomy to manage small bowel obstruction due to superior mesenteric artery syndrome after Roux-en-Y gastric bypass
Superior mesenteric artery (SMA) syndrome (Wilkie or cast syndrome) is a rare disease that was first described in 1842. It is seen in patients most often after dramatic weight loss due to starvation, burns, anorexia nervosa, or bariatric surgery.Laparoscopic conversion from mini gastric bypass/1 anastomosis gastric bypass to Roux-en-Y gastric bypass for perforated marginal ulcer: video case report
In 1997, Rutledge [1] introduced a new bariatric procedure consisting of a single anastomosis gastric bypass, which he named a mini gastric bypass (MGB).Single and dual anastomosis duodenal switch for obesity treatment: a single-center experience
Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking.Effect of surgical versus medical therapy on estimated cardiovascular event risk among adolescents with type 2 diabetes and severe obesity
Cardiovascular disease (CVD) remains the leading cause of mortality in type 2 diabetes (T2D). Better interventions are needed to mitigate the high lifetime risk for CVD in youth T2D.Counterregulatory responses to postprandial hypoglycemia after Roux-en-Y gastric bypass
Postbariatric hypoglycemia (PBH) is a potentially serious complication after Roux-en-Y gastric bypass (RYGB), and impaired counterregulatory hormone responses have been suggested to contribute to the condition.Factors implicated in discharge disposition following elective bariatric surgery
Current bariatric surgery studies have focused on traditional outcomes such as mortality and morbidity and have thus far have neglected an important marker of surgical care- discharge destination.Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass
Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease–related complications.Long-term outcomes of Roux-en-Y gastric diversion after failed surgical fundoplication in a large cohort and a systematic review
Roux-en-Y gastric diversion (RNYG) is an alternative approach for patients with persistent or recurrent gastroesophageal reflux disease (GERD) after surgical fundoplication, especially in patients with esophageal dysmotility or morbid obesity, because redo fundoplication could offer unfavorable outcomes.First prospective clinical trial of reduced incision bariatric procedures using magnetic liver retraction
Exposure of the surgical field is an essential component of minimally invasive surgery. Liver retraction is an important element of bariatric procedures because visualization of the stomach and gastroesophageal junction is key. The magnetic surgical system provides a well-tolerated and effective option for adjustable liver retraction without the use of a dedicated port.Laparoscopic modified Nissen fundoplication over Roux-en-Y gastric bypass and hiatal hernia repair for intractable gastroesophageal reflux
Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity and gastroesophageal reflux disease (GERD) [1] Despite majority of patients with resolution of GERD after RYGB, some patients will continue to complain of significant, persistent reflux symptomatology or develop de novo symptoms despite aggressive medical management. Its true incidence is unknown and 1 study showed an improvement in GERD but not resolution in 22% of patients after RYGB with GERD [2]. Possible mechanisms may include primary lower esophageal sphincter incompetence, disruption of the angle of His, or development of hiatal hernia with intrathoracic migration of the gastric pouch.Laparoscopic sleeve gastrectomy after endoscopic sleeve gastroplasty and primary obesity surgery endoluminal: technical aspects
Endoscopic techniques have emerged as effective treatments for overweight and obesity; the intragastric balloon is the most widely practiced procedure [1]. Endoscopic sleeve gastroplasty (ESG) entails gastric volume reduction via placement of full-thickness suturing of the anterior wall, greater curvature, and posterior wall of the stomach. The stomach is imbricated and shortened from the antrum to the gastroesophageal junction to create sleeve-like anatomy by using The OverStitch device (Apollo Endosurgery, Austin, TX, USA) [2].Laparoscopic resection of intussusception after Roux-en-Y gastric bypass: comparison between the conventional and a simplified approach
Intussusception after Roux-en-Y gastric bypass (RYGB) is a rare, long-term complication most commonly occurring in a retrograde fashion just distal to the jejunojejunostomy with approximately .5% incidence [1]. Management options include reduction, pexy, and resection of jejunojejunostomy [2–4]. Our traditional approach in management of symptomatic intussusception is resection and creation of new jejunojejunostomy,y preferably end-to-side anastomosis with a smaller anastomosis of <60 mm. In this video, we compare 2 techniques used to resect the anastomosis.Laparoscopic revision of a transected silastic vertical gastric bypass (Fobi pouch) with totally hand sewn gastrojejunostomy for complicated marginal ulcer
Transected silastic vertical gastric bypass (Fobi pouch bypass) is a modified open gastric bypass, introduced by Dr. Mathias Fobi in 1990s. Although long-term weight maintenance is excellent, it was not widely adopted by bariatric surgeons in the minimally invasive era. This video illustrates a laparoscopic approach to a particularly complicated marginal ulcer that was eroding into the liver and pancreas.Comment on: Slipped capital femoral epiphysis and Blount’s disease as indicators for early metabolic surgical intervention
Patient selection criteria for adolescent metabolic bariatric surgery (MBS) have historically included adolescents who have achieved an extreme body mass index value, have developed a major complication of their obesity that would justify surgical therapy, show evidence of physiologic maturity evidence of mature decision-making, and demonstrate understanding of the dietary and physical activity changes that are required for optimal postoperative outcomes.Laparoscopic repair of diaphragmatic hernia with mesh after sleeve gastrectomy
The patient was a 46-year-old female with a history of morbid obesity and was post–laparoscopic sleeve gastrectomy (performed at an outside institution), complicated by a left diaphragmatic thermal injury. On review of the sleeve gastrectomy operative dictation, an approximately 3-cm defect was incidentally made in the left diaphragm by a harmonic scalpel; this was repaired primarily with interrupted permanent suture at that time. She presented 3 years later with a several-day history of emesis, obstipation, and left upper quadrant abdominal pain.Eating expectancies before bariatric surgery: assessment and associations with weight loss trajectories
While presurgical eating behaviors have demonstrated limited prognostic value, cognitions regarding the effects of eating may serve as important predictors of weight loss outcomes after bariatric surgery. The Eating Expectancies Inventory (EEI) is a commonly used, self-report measure of expected consequences of eating; however, its psychometric and predictive properties have not yet been evaluated among bariatric surgery patients.Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry
Bleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG.Sleeve gastrectomy in patients with previous antireflux surgery. Preliminary results of the “no-touch to posterior wrap” technique
Reported morbidity of Roux-en-Y gastric bypass in patients with previous antireflux surgery warrants caution, and data on sleeve gastrectomy (SG) are unexpectedly scarce.Combined robotic/laparoscopic sleeve gastrectomy with transit bipartition for an obese patient with complicated metabolic syndrome
A recent international consensus conference stated that metabolic surgery should be a recommended option to treat diabetes regardless of the level of glycemic control. This video demonstrates combined robotic/laparoscopic sleeve gastrectomy with transit bipartition for an obese patient with complicated metabolic syndrome. The procedure was performed at a university hospital.Clinical periodontal conditions in individuals after bariatric surgery: a systematic review and meta-analysis
The aim of the present study was to perform a systematic review and meta-analysis to assess the influence of bariatric surgery on the clinical periodontal conditions in patients with obesity. This review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered at the International Prospective Registry of Systematic Reviews (CRD42018099313). A search was conducted by 2 investigators in the PubMed/MEDLINE, Web of Science, and Cochrane Library databases for relevant articles published up to May 2018.One-year follow-up of a dissonance-based intervention on quality of life, wellbeing, and physical activity after Roux-en-Y gastric bypass surgery: a randomized controlled trial
Health-related quality of life (HRQoL) peaks around 1 year after Roux-en-Y gastric bypass (RYGB) surgery, and thereafter, in many patients, slowly deteriorates.Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study
Reproductive-aged women constitute a substantial proportion of patients who undergo weight loss procedures. While the risk of gallstone disease after such procedures has been addressed extensively, the impact of pregnancy on gallstone disease after bariatric procedures has not been reported.Psychometric properties of the eating loss of control scale among postbariatric patients
Assessing the complexities of eating behaviors in patients who undergo bariatric surgery is challenging. The Eating Loss of Control Scale (ELOCS), a measure of loss-of-control (LOC) eating, has not yet been evaluated psychometrically among bariatric surgery patients.Robotic-assisted conversion of Nissen fundoplication to Roux-en-Y gastric bypass (avoiding pitfalls)
Conversion of Nissen fundoplication to Roux-en-Y gastric bypass can be technically challenging due to factors present for any reoperation, such as presence of scar tissue, altered tissue planes, and often unclear anatomy. Meticulous hiatus and wrap dissection, repair of hiatal hernia if present, complete unwrapping of the fundoplication and clarification of gastric redundancy before pouch creation, and preservation of the left gastric artery are keys to improving outcomes and reducing morbidity.Laparoscopic sleeve gastrectomy for class III obesity in a patient with a left ventricular assist device (LVAD) Heartmate III
We describe the successful management of an obese patient suffering end-stage heart failure by the combination mechanical circulatory support, using a left ventricular assist device (LVAD), and bariatric surgery, using laparoscopic sleeve gastrectomy (LSG).Intragastric single-port surgery (IGS) accesses the gastric remnant and allows ERCP for common bile duct stones after RYGB: a simple solution for a difficult problem
Patients who have undergone a Roux-en-Ygastric bypass (RYGB) and suffer from choledocholithiasis postoperatively pose a medical dilemma. Treatment of the cholestasis can be complicated because of the altered anatomy in these patients. The gastric remnant and duodenum are isolated from the pancreaticobiliary limb, making endoscopic retrograde pancreatography (ERCP) challenging and often impossible.Micro-laparoscopic sleeve gastrectomy using reduced size ports and instruments: technical points
Sleeve gastrectomy (SG) is the most popular bariatric procedure worldwide [1] because of weight loss maintenance and acceptable morbidity [2,3]. Reduced-port SG (i.e., 3 trocars) has emerged as a new standard providing safety and efficacy [4,5] comparable with that of the 5-port technique. However, liver retraction and incisional hernia remain unresolved issues [6]. Single-incision SG has been proposed as a minimal invasive alternative that allows outcomes similar to the 5-port technique as well as better analgesia and cosmesis in selected patients [7].Comment on: Safety and effectiveness of single anastomosis DS versus double anastomosis DS
I congratulate the authors for publishing their comparative experience with single-anastomosis duodenal switch (SADI-S) and 2-anastomosis duodenal switch (DS). The literature continues to grow with reports of modified bariatric operations, including variable limb lengths for primary or revisional Roux-en-Y gastric bypass, 1-anastomosis gastric bypass, DS, and SADI-S varieties [1–13]. It is vitally important to report outcome data on these various modifications to better understand the impact of these changes (sleeve size, alimentary limb length, and common channel length), reconcile the clinical and physiologic consequences, and learn how to select the safest and most efficacious procedures for our patients.Sleeve gastrectomy in obese Wistar rats improves diastolic function and promotes cardiac recovery independent of weight loss
Heart failure with preserved ejection fraction is the most common cause of heart failure and is characterized by impaired diastolic relaxation. Bariatric surgery significantly improves diastolic relaxation, but a mechanism beyond weight loss remains unknown.Time savings and accuracy of a simulated flexible and conditional administration of the MMPI-2-RF in presurgical psychological evaluations of bariatric surgery candidates
Broadband psychological tests like the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) [1] are recommended for use in presurgical psychological assessments of bariatric surgery patients [2] because of research literature supporting the utility of the test in this setting [3-6]. For example, Marek et al. [5] found that scores from the test predicted appointment adherence and weight loss outcomes 1 year postsurgery. Nevertheless, psychologists conducting these evaluations tend to administer shorter, more symptom-focused measures rather than broadband instruments with longer administration times [7].Mental disorders and weight change in a prospective study of bariatric surgery patients: 7 years of follow-up
Long-term, longitudinal data are limited on mental disorders after bariatric surgery.Changes of gut microbiota between different weight reduction programs
Gut microbiota may induce obesity, diabetes, and metabolic syndrome. Different weight reduction programs may induce different changes in gut microbiota.Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients
Diabetes is an epidemic disease and is estimated to affect >300 million people worldwide in 2025 [1]. Type 2 diabetes (T2D) management is a combination of diet, lifestyle modifications, and drug therapy. Recently, many studies have shown remission of T2D in obese population [2–6]. Buchwald et al. [2] in his systemic review and meta-analysis showed that diabetes remission rates were 99% (95% confidence interval, 97%–100%) after biliopancreatic diversion, 84% (95% confidence interval, 77%–90%) after Roux-en-Y gastric bypass (RYGB), and 48% (95% confidence interval, 29%–67%) after gastric banding.Recent trends in intensive treatments of obesity: Is academic research matching public interest?
Overweight and obesity continues to be a serious public health concern. The World Health Organization estimated that the worldwide prevalence of obesity nearly tripled between 1975 and 2016, with 1.9 bilion adults being overweight in 2016 and, of these, 650 million were obese [1]. In addition to the pandemic escalation of obesity in developed nations, obesity is now on the rise in developing countries, such as China, India, and the rest of Asia. The World Health Organization estimates that >1.7 billion people worldwide are overweight or obese [2].Duodenal switch: Fully stapled technique
Duodenal switch and single anastomosis modifications continue to gain greater interest among bariatric surgeons. Limiting factors to adoption include concerns around the nutritional management, patient compliance and follow-up, and the technical challenge of the operation. The majority of techniques offered currently use a hand-sewn duodenoileostomy. This approach is limited by the steep learning curve as well as longer operating times.Improvement in pulmonary function in asthmatic patients after bariatric surgery: a systematic review and meta-analysis
Asthma is a common respiratory disorder that affects 1 in 13 people, and at least 25 million people in the United States have asthma [1,2]. Another evolving public health problem is obesity, which is a condition that affects millions of Americans and that causes a large and growing economic burden on healthcare systems in the United States [3]. Many observational studies found and reported association between asthma and obesity. Increased rates of prevalence of, disease exacerbation in, and risk of hospitalization for asthma are reported in obese patients [4–6].Is age a real or perceived discriminator for bariatric surgery? A long-term analysis of bariatric surgery in the elderly
Obesity has become an epidemic in the United States and around the world. At the same time, we are seeing an aging of human populations both nationally and globally. The U.S. Census Bureau projects that the percentage of the population aged ≥65 years will increase from 13.7% in 2012 to 16.8% in 2020 to 20.3% in 2030 [1]. This trend holds true on the global scale with 8.5% of the world population being ≥65 years in 2015, and expected to nearly double to 16.7% in 2050. From 2011 to 2014 the obesity rate in the U.S.Strategies for diagnosing and managing gastric diverticulum in sleeve gastrectomy
A gastric diverticulum is an uncommon abnormality in which there is an outpouching of the gastric wall. They are usually asymptomatic and found incidentally on imaging [1]. Rarely, gastric diverticula can cause a variety of gastrointestinal symptoms, such as epigastric pain, nausea, vomiting, and reflux [2]. These symptoms are typically well managed with antacid medications, and surgical intervention is only warranted if medical therapy fails [3].Laparoscopic conversion of Roux-en-Y gastric bypass to omega loop gastric bypass
The Roux-en-Y gastric bypass (RYGB) has been performed for>3 decades and is the procedure of choice for severe obesity with metabolic disorders in most of the bariatric surgical centers worldwide [1]. Nevertheless, RYGB is a technically demanding procedure, with a learning curve of>75 cases and a complication rate ranging between 5% and 10% [2,3]. RYGB has been the standard procedure in bariatric surgery; however, some patients have not achieved the intended weight loss. In contrast, omega loop bypass (OLB) has proven to have greater efficacy in weight loss and remission of type 2 diabetes in 1 year [4].Three-trocar laparoscopic duodenal switch after sleeve gastrectomy
Laparoscopic duodenal switch is a recognized bariatric procedure, which can be performed in one step or as a second step after laparoscopic sleeve gastrectomy (LSG). Mainly, indications as primary surgery are super-obese or super super-obese patients, and after LSG indications are the presence of insufficient weight loss or weight regain, associated with morbid obesity co-morbidities, without gastroesophageal reflux. In this video, the authors report the technique of reduced port laparoscopic duodenal switch after LSG.Laparoscopic transhiatal esophagectomy after biliopancreatic diversion with duodenal switch
The incidence of esophageal adenocarcinoma has steadily risen paralleling the global rise in obesity [1]. There appears to be a strong association between increasing body mass index and incidence of esophageal adenocarcinoma. There is insufficient data to indicate that this risk abates after weight loss surgery [2]. Additionally, previous bariatric surgery, particularly sleeve gastrectomy (SG), poses significant technical challenges in reconstruction after esophageal resection. Primarily, the right gastroepiploic artery feeds the gastric conduit in transhiatal esophagectomy after the left gastric artery is divided.Laparoscopic Heller myotomy after previous Roux-en-Y gastric bypass
Obesity has been shown to be an independent risk factor for developing esophageal motility disorders, with a prevalence of 20% to 61% [1–4]. Achalasia is a rare primary esophageal motility disorder that is even more rare among the obese population. It is characterized by aperistalsis of the esophagus and lack of relaxation of the lower esophageal sphincter. Associated symptoms in the nonobese patient include dysphagia, regurgitation, reflux, and weight loss. On the contrary, among the obese population regurgitation, cough and aspiration are the presenting symptoms.Endoscopic management of erosion after banded bariatric procedures
Prosthetic materials wrapped around a portion of the stomach have been used to provide gastric restriction in bariatric surgery for many years. Intraluminal erosion of adjustable and nonadjustable gastric bands typically occurs many years after placement and results in various symptoms. Endoscopic management of gastric band erosion has been described and allows for optimal patient outcomes.Surgical management of enterolith ileus after Roux-en-Y gastric bypass
Roux-en-Y gastric bypass (RYGB) is the second most common bariatric procedure performed worldwide (39.6%) [1]. However, despite low mortality rates [2], this procedure is not free of complications [3]. Small bowel obstruction (SBO) after RGYB has an incidence of 7.3% [4]. It is most commonly caused by adhesions (33%) and internal herniation (31%) [5]. Enterolith ileus (EI) is an uncommon cause of SBO generated by intraluminal stone formation. Primary enterolithiasis occurs in areas of stasis associated with intestinal diverticula, enteroanastomosis, afferent loops in Roux-en-Y procedures, intestinal kinking, stenosis and strictures, tumors, and hernias [6].Sociodemographic and lifestyle factors as determinants of energy intake and macronutrient composition: a 10-year follow-up after bariatric surgery
Early identification of the potential to adopt a long-term unhealthy diet, could improve weight outcomes for patients having undergone bariatric surgery.Laparoscopic approach to a bleeding marginal ulcer fistulized to the gastric remnant in a patient post Roux-en-Y gastric bypass
Roux-en-Y gastric bypass (RYGB) is the most effective treatment for morbid obesity; however, it is not without complications. Marginal ulcers, defined as ulcers at the gastrojejunal anastomosis, are among the most common long-term complications of RYGB. Although the exact etiology is not yet fully understood, the incidence ranges from .6%–16% [1–3]. In most cases, marginal ulcers can be successfully treated with proton pump inhibitors and cytoprotective barriers, along with the cessation of nonsteroidal anti-inflammatory drugs (NSAIDs) and smoking [2].Surgery-related gastrointestinal symptoms in a prospective study of bariatric surgery patients: 3-year follow-up
Having accurate information on bariatric surgery-related gastrointestinal (GI) symptoms is critical for patient care.
